Provider Demographics
NPI:1831681071
Name:TYSON, KIRSTIE A (ALC)
Entity type:Individual
Prefix:
First Name:KIRSTIE
Middle Name:A
Last Name:TYSON
Suffix:
Gender:F
Credentials:ALC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11087
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-0087
Mailing Address - Country:US
Mailing Address - Phone:334-280-3349
Mailing Address - Fax:334-356-1426
Practice Address - Street 1:2900 MCGEHEE RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2151
Practice Address - Country:US
Practice Address - Phone:334-280-3349
Practice Address - Fax:334-356-1426
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL2799OtherALC