Provider Demographics
NPI:1962287003
Name:TENNESSEE, TYRONE RAUL (LCDC-I)
Entity type:Individual
Prefix:
First Name:TYRONE
Middle Name:RAUL
Last Name:TENNESSEE
Suffix:
Gender:M
Credentials:LCDC-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 E QUINCY ST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78215-1632
Mailing Address - Country:US
Mailing Address - Phone:210-299-1614
Mailing Address - Fax:
Practice Address - Street 1:519 E QUINCY ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78215-1632
Practice Address - Country:US
Practice Address - Phone:210-299-1614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)