Provider Demographics
NPI:1588486070
Name:JOHNSON, TYRONE
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6737 W WASHINGTON ST STE 2275
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-5666
Mailing Address - Country:US
Mailing Address - Phone:414-246-2300
Mailing Address - Fax:
Practice Address - Street 1:3872 N 8TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53206-3303
Practice Address - Country:US
Practice Address - Phone:414-252-0210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI8176-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health