Healthcare Provider Details

I. General information

NPI: 1912990482
Provider Name (Legal Business Name): TIYOSPAYE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 N MARKET ST
WICHITA KS
67202-2003
US

IV. Provider business mailing address

247 N MARKET ST
WICHITA KS
67202-2003
US

V. Phone/Fax

Practice location:
  • Phone: 316-262-2060
  • Fax: 316-262-2740
Mailing address:
  • Phone: 316-262-2060
  • Fax: 316-262-2740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number412
License Number StateKS

VIII. Authorized Official

Name: MS. MARY SAN MARTIN
Title or Position: CEO
Credential:
Phone: 316-262-2060