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NPI Code Detail

MEDICARE: ANTORRIA DION TYSON

MEDICARE: ANTORRIA DION TYSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1103K00000XBehavior Analyst

General Provider Information

NPI Number : 1629538582
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANTORRIA DION TYSON
Provider Business Mailing Address
First Line : 141 CALUMET LOOP
Second Line :
City : ELIZABETHTOWN
State : KY
Zip : 42701-4484
Country : US
Telephone Number : 337-353-8336
Fax Number :
Provider Business Practice Location Address
First Line : 1239 WOODLAND DR STE 112
Second Line :
City : ELIZABETHTOWN
State : KY
Zip : 42701-3723
Country : US
Telephone Number : 502-358-5106
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/25/2019
Last Update Date : 03/25/2019

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Directions to “ ANTORRIA DION TYSON ” Practice Location

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