Provider Demographics
NPI:1952587792
Name:PROUSE, TYSON BLAKE (MS, T-LMLP)
Entity Type:Individual
Prefix:MR
First Name:TYSON
Middle Name:BLAKE
Last Name:PROUSE
Suffix:
Gender:M
Credentials:MS, T-LMLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S GORDY ST STE 3
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:KS
Mailing Address - Zip Code:67042-2900
Mailing Address - Country:US
Mailing Address - Phone:316-321-6088
Mailing Address - Fax:316-321-3957
Practice Address - Street 1:120 S GORDY ST STE 3
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:KS
Practice Address - Zip Code:67042-2900
Practice Address - Country:US
Practice Address - Phone:316-321-6088
Practice Address - Fax:316-321-3957
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KST-LMLP 1146103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical