Provider Demographics
NPI:1780316554
Name:TYSON, TANJULLA
Entity type:Individual
Prefix:
First Name:TANJULLA
Middle Name:
Last Name:TYSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17619 THROCKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-1607
Mailing Address - Country:US
Mailing Address - Phone:216-240-3300
Mailing Address - Fax:
Practice Address - Street 1:17619 THROCKLEY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-1607
Practice Address - Country:US
Practice Address - Phone:216-240-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker