Healthcare Provider Details

I. General information

NPI: 1104885433
Provider Name (Legal Business Name): TYSON BAIZE MSW, LCSW,BCD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 02/19/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

448 USS FLORIDA CT APT 4
STATEN ISLAND NY
10305-5048
US

IV. Provider business mailing address

448 USS FLORIDA CT APT 4
STATEN ISLAND NY
10305-5048
US

V. Phone/Fax

Practice location:
  • Phone: 859-935-7735
  • Fax:
Mailing address:
  • Phone: 859-935-7735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2004007336
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: