Provider Demographics
NPI:1750941738
Name:ROBERTS, TYRA
Entity type:Individual
Prefix:
First Name:TYRA
Middle Name:
Last Name:ROBERTS
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 1:10 W EAGER ST STE 200
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21201-5469
Mailing Address - Country:US
Mailing Address - Phone:410-622-5887
Mailing Address - Fax:
Practice Address - Street 1:10 W EAGER ST STE 200
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5469
Practice Address - Country:US
Practice Address - Phone:410-622-5887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-20
Last Update Date:2023-08-31
Deactivation Date:2019-06-24
Deactivation Code:
Reactivation Date:2023-08-31
Provider Licenses
StateLicense IDTaxonomies
MD101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD916788Medicaid