Provider Demographics
NPI:1588146062
Name:TYSON, KAREN MICHELLE (LADC)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:MICHELLE
Last Name:TYSON
Suffix:
Gender:F
Credentials:LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 7720
Mailing Address - Street 2:CREDENTIALING SPECIALIST
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06519-0720
Mailing Address - Country:US
Mailing Address - Phone:203-503-3174
Mailing Address - Fax:203-503-3183
Practice Address - Street 1:62 GRANT STREET
Practice Address - Street 2:GRANT STREET PARTNERSHIP
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06519-3456
Practice Address - Country:US
Practice Address - Phone:203-503-3350
Practice Address - Fax:203-503-3370
Is Sole Proprietor?:No
Enumeration Date:2018-08-31
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1305101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)