Provider Demographics
NPI:1124649090
Name:TYSON, ELENA AURORA (PHD)
Entity type:Individual
Prefix:DR
First Name:ELENA
Middle Name:AURORA
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 1:800 BRADBURY DR SE STE 116
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:2600 COLLEGE AVE NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87144-2103
Practice Address - Country:US
Practice Address - Phone:505-994-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-02
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPSY-2023-0024103TP2701X, 103T00000X, 103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup Psychotherapy
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1285628552OtherANDRUS