Provider Demographics
NPI:1477543643
Name:TYSOR-TETLEY, MARY E (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:TYSOR-TETLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:TYSOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:339 CAJON ST
Mailing Address - Street 2:STE B
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5901
Mailing Address - Country:US
Mailing Address - Phone:909-783-1078
Mailing Address - Fax:909-801-8070
Practice Address - Street 1:339 CAJON ST
Practice Address - Street 2:STE B
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5901
Practice Address - Country:US
Practice Address - Phone:909-783-1078
Practice Address - Fax:909-801-8070
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAT145531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
11634766OtherCAQH
ZZZ132932Medicare ID - Type Unspecified