Provider Demographics
NPI:1730598665
Name:TYSON, KATHERINE ELIZABETH (PHD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ELIZABETH
Last Name:TYSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SAGE RD
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-6995
Mailing Address - Country:US
Mailing Address - Phone:919-942-4166
Mailing Address - Fax:
Practice Address - Street 1:205 SAGE RD
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-6995
Practice Address - Country:US
Practice Address - Phone:919-942-4166
Practice Address - Fax:919-942-8693
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2015-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC4840103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent