Provider Demographics
NPI:1104591775
Name:CARTER, TYRESE LOIS
Entity type:Individual
Prefix:
First Name:TYRESE
Middle Name:LOIS
Last Name:CARTER
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 1:19 LERNER CT
Mailing Address - Street 2:
Mailing Address - City:NOTTINGHAM
Mailing Address - State:MD
Mailing Address - Zip Code:21236-3009
Mailing Address - Country:US
Mailing Address - Phone:443-969-5542
Mailing Address - Fax:
Practice Address - Street 1:19 LERNER CT
Practice Address - Street 2:
Practice Address - City:NOTTINGHAM
Practice Address - State:MD
Practice Address - Zip Code:21236-3009
Practice Address - Country:US
Practice Address - Phone:443-969-5542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-14
Last Update Date:2022-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP11244101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional