Provider Demographics
NPI:1699157438
Name:TYRE, IASIA (LCSWC)
Entity type:Individual
Prefix:MISS
First Name:IASIA
Middle Name:
Last Name:TYRE
Suffix:
Gender:F
Credentials:LCSWC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 ISLAND GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-3313
Mailing Address - Country:US
Mailing Address - Phone:718-775-1992
Mailing Address - Fax:
Practice Address - Street 1:2625 ISLAND GROVE BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-3313
Practice Address - Country:US
Practice Address - Phone:718-775-1992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-28
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD179001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical