Provider Demographics
NPI:1326379678
Name:WILLOUGHBY, TYRONE DELANO JR (LCSW-C)
Entity type:Individual
Prefix:MR
First Name:TYRONE
Middle Name:DELANO
Last Name:WILLOUGHBY
Suffix:JR
Gender:M
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 ARTHUR AVE
Mailing Address - Street 2:
Mailing Address - City:PORT DEPOSIT
Mailing Address - State:MD
Mailing Address - Zip Code:21904-1247
Mailing Address - Country:US
Mailing Address - Phone:410-419-0811
Mailing Address - Fax:
Practice Address - Street 1:155 ARTHUR AVE
Practice Address - Street 2:
Practice Address - City:PORT DEPOSIT
Practice Address - State:MD
Practice Address - Zip Code:21904-1247
Practice Address - Country:US
Practice Address - Phone:410-419-0811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-27
Last Update Date:2010-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD150411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical