Provider Demographics
NPI:1831442110
Name:TYSON'S CORNER HEALTH SERVICES, INC
Entity type:Organization
Organization Name:TYSON'S CORNER HEALTH SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:CASPERTINE
Authorized Official - Middle Name:ANNTIONELLE
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:QP
Authorized Official - Phone:202-531-6736
Mailing Address - Street 1:8317 SIX FORKS RD
Mailing Address - Street 2:STE. 101
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-2104
Mailing Address - Country:US
Mailing Address - Phone:252-217-4681
Mailing Address - Fax:252-364-2631
Practice Address - Street 1:482 WILLIAMSTON DR
Practice Address - Street 2:
Practice Address - City:WINTERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28590-9415
Practice Address - Country:US
Practice Address - Phone:252-217-4681
Practice Address - Fax:252-364-2631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101YA0400X, 101YM0800X, 101YP2500X, 103T00000X, 103TC1900X, 103TP2701X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Multi-Specialty