Provider Demographics
NPI:1912311549
Name:FERNANDEZ-TYSON, TERRI (PHD)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:FERNANDEZ-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:PO BOX 330
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:MT
Mailing Address - Zip Code:59624-0330
Mailing Address - Country:US
Mailing Address - Phone:406-431-3790
Mailing Address - Fax:
Practice Address - Street 1:301 N WARREN ST
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59601-4030
Practice Address - Country:US
Practice Address - Phone:406-431-3790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-11
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTPSY-PSY-LIC-1193103T00000X
IDPSY-202256103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist