Healthcare Provider Details

I. General information

NPI: 1326536376
Provider Name (Legal Business Name): TYRONE ANDERSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2018
Last Update Date: 04/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5910 W DIVISION ST
CHICAGO IL
60651-1031
US

IV. Provider business mailing address

5910 W DIVISION ST
CHICAGO IL
60651-1031
US

V. Phone/Fax

Practice location:
  • Phone: 773-777-7112
  • Fax: 773-887-3300
Mailing address:
  • Phone: 773-777-7112
  • Fax: 773-887-3300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number11457
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: