Healthcare Provider Details

I. General information

NPI: 1063085462
Provider Name (Legal Business Name): MATTHEW TYRA LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2021
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3438 EMMORTON RD # 16
ABINGDON MD
21009-2016
US

IV. Provider business mailing address

3438 EMMORTON RD # 16
ABINGDON MD
21009-2016
US

V. Phone/Fax

Practice location:
  • Phone: 803-642-3980
  • Fax:
Mailing address:
  • Phone: 803-642-3980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: