Provider Demographics
NPI:1902056211
Name:TYSON, JUNE (LCSW-R)
Entity Type:Individual
Prefix:DR
First Name:JUNE
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4149 HIBISCUS DR APT 303
Mailing Address - Street 2:
Mailing Address - City:LITTLE RIVER
Mailing Address - State:SC
Mailing Address - Zip Code:29566-8384
Mailing Address - Country:US
Mailing Address - Phone:347-575-8368
Mailing Address - Fax:
Practice Address - Street 1:901 N KINGS HWY
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-3722
Practice Address - Country:US
Practice Address - Phone:843-448-4820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-23
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0785801041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244019Medicaid