Healthcare Provider Details

I. General information

NPI: 1558630434
Provider Name (Legal Business Name): SARAH ANN TYSSELAND-MCMINN LSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2011
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 MORENA BLVD
SAN DIEGO CA
92110-3815
US

IV. Provider business mailing address

1250 MORENA BLVD
SAN DIEGO CA
92110-3815
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-8715
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number74083
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number74083
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: