Healthcare Provider Details

I. General information

NPI: 1720698939
Provider Name (Legal Business Name): BLUE RIDGE BEHAVIOR SYSTEMS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2020
Last Update Date: 08/03/2020
Certification Date: 08/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16147 LANCASTER HWY STE 110
CHARLOTTE NC
28277-4196
US

IV. Provider business mailing address

16426 HAWFIELD WOODS LN
CHARLOTTE NC
28277-6108
US

V. Phone/Fax

Practice location:
  • Phone: 704-540-4291
  • Fax: 704-541-0319
Mailing address:
  • Phone: 704-540-4291
  • Fax: 704-541-0319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM MICHAEL TYSON
Title or Position: PSYCHOLOGIST
Credential: PHD
Phone: 704-540-4291