Healthcare Provider Details

I. General information

NPI: 1790763308
Provider Name (Legal Business Name): WILLIAM MICHAEL TYSON PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 07/28/2020
Certification Date: 07/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16426 HAWFIELD WOODS LN
CHARLOTTE NC
28277-6108
US

IV. Provider business mailing address

16147 LANCASTER HWY STE 110
CHARLOTTE NC
28277-4196
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 Number1169
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1169
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License Number1169
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number1169
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: