Provider Demographics
NPI:1497204473
Name:TYSON, KATHERINE (PHLD LCSW)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:PHLD LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 N WABASH AVE
Mailing Address - Street 2:509
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3591
Mailing Address - Country:US
Mailing Address - Phone:312-329-1561
Mailing Address - Fax:
Practice Address - Street 1:405 N WABASH AVE
Practice Address - Street 2:509
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3591
Practice Address - Country:US
Practice Address - Phone:312-329-1561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-01
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490001921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical