Provider Demographics
NPI:1992964787
Name:TYSON, SEANNE SHELLY (PHD)
Entity type:Individual
Prefix:DR
First Name:SEANNE
Middle Name:SHELLY
Last Name: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 1:2311 W EL SEGUNDO BLVD
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-3315
Mailing Address - Country:US
Mailing Address - Phone:323-241-6730
Mailing Address - Fax:323-756-1163
Practice Address - Street 1:2311 W EL SEGUNDO BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-3315
Practice Address - Country:US
Practice Address - Phone:323-241-6730
Practice Address - Fax:323-756-1163
Is Sole Proprietor?:No
Enumeration Date:2008-06-05
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY17017103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical