Healthcare Provider Details

I. General information

NPI: 1902056211
Provider Name (Legal Business Name): JUNE TYSON LCSW-R
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2008
Last Update Date: 04/20/2022
Certification Date: 04/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 N KINGS HWY
MYRTLE BEACH SC
29577-3722
US

IV. Provider business mailing address

4149 HIBISCUS DR APT 303
LITTLE RIVER SC
29566-8384
US

V. Phone/Fax

Practice location:
  • Phone: 843-448-4820
  • Fax:
Mailing address:
  • Phone: 347-575-8368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number078580
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00244019
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: