Provider Demographics
NPI:1700493228
Name:OXENDINE, TYRA
Entity Type:Individual
Prefix:
First Name:TYRA
Middle Name:
Last Name:OXENDINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 LOCKEY RD
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE
Mailing Address - State:NC
Mailing Address - Zip Code:28372-8785
Mailing Address - Country:US
Mailing Address - Phone:910-610-9794
Mailing Address - Fax:
Practice Address - Street 1:1779 S MAIN ST
Practice Address - Street 2:
Practice Address - City:LAURINBURG
Practice Address - State:NC
Practice Address - Zip Code:28352-5407
Practice Address - Country:US
Practice Address - Phone:910-277-3212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-29
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
NC15887101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health