Provider Demographics
NPI:1720086564
Name:TYSON, JUDY ANN (PHD)
Entity Type:Individual
Prefix:MS
First Name:JUDY
Middle Name:ANN
Last Name:TYSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8915 SHADY GROVE CT
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20877-1308
Mailing Address - Country:US
Mailing Address - Phone:301-963-0060
Mailing Address - Fax:301-258-8858
Practice Address - Street 1:8915 SHADY GROVE CT
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20877-1308
Practice Address - Country:US
Practice Address - Phone:301-963-0060
Practice Address - Fax:301-258-8858
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1966103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist