Healthcare Provider Details

I. General information

NPI: 1932768579
Provider Name (Legal Business Name): SANDRA DIANE TYSON RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 COMPASS RD
GLENVIEW IL
60026-8001
US

IV. Provider business mailing address

1514 JOHNATHAN ST
HYATTSVILLE MD
20782-3457
US

V. Phone/Fax

Practice location:
  • Phone: 202-854-7100
  • Fax:
Mailing address:
  • Phone: 202-854-7657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251G0304X
TaxonomyGeriatric Physical Therapist
License Number0542
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: