Provider Demographics
NPI:1740830439
Name:TYSON, TAWANNA
Entity type:Individual
Prefix:
First Name:TAWANNA
Middle Name:
Last Name:TYSON
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 1:3558 E 142ND ST APT 1
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44120-5805
Mailing Address - Country:US
Mailing Address - Phone:216-905-3080
Mailing Address - Fax:
Practice Address - Street 1:1744 PAYNE AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44114-2910
Practice Address - Country:US
Practice Address - Phone:216-623-6555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2020-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.2001477-TRNE104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker