Healthcare Provider Details

I. General information

NPI: 1083144521
Provider Name (Legal Business Name): TYRONE OBASEKI LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2017
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1631 E 2ND ST
AUSTIN TX
78702-4490
US

IV. Provider business mailing address

PO BOX 55040
VIRGINIA BEACH VA
23471-5040
US

V. Phone/Fax

Practice location:
  • Phone: 757-288-6365
  • Fax: 757-767-4025
Mailing address:
  • Phone: 757-288-6365
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number71993
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: