Provider Demographics
NPI:1750791885
Name:TYSON-JOHNSON, FELICIA
Entity type:Individual
Prefix:
First Name:FELICIA
Middle Name:
Last Name:TYSON-JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FELICIA
Other - Middle Name:HOLLY
Other - Last Name:TYSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5306 NC HIGHWAY 55
Mailing Address - Street 2:STE 105
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-7812
Mailing Address - Country:US
Mailing Address - Phone:919-457-1517
Mailing Address - Fax:919-363-7697
Practice Address - Street 1:5306 NC HIGHWAY 55
Practice Address - Street 2:STE 105
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713-7812
Practice Address - Country:US
Practice Address - Phone:919-457-1517
Practice Address - Fax:919-363-7697
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-28
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0097401041C0700X
251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty