Provider Demographics
NPI:1548080823
Name:TYSON, VERDALE (LPC)
Entity type:Individual
Prefix:
First Name:VERDALE
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:VERDALE
Other - Middle Name:
Other - Last Name:TYSON-HARRIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:119 S WESTERN AVE # 364
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4643
Mailing Address - Country:US
Mailing Address - Phone:773-230-1217
Mailing Address - Fax:
Practice Address - Street 1:119 S WESTERN AVE # 364
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4643
Practice Address - Country:US
Practice Address - Phone:773-230-1217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178020721101Y00000X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor