Healthcare Provider Details

I. General information

NPI: 1154696359
Provider Name (Legal Business Name): TIYA SHALYSE JOHNSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11937 US HIGHWAY 271
TYLER TX
75708-3154
US

IV. Provider business mailing address

11937 US HIGHWAY 271
TYLER TX
75708-3154
US

V. Phone/Fax

Practice location:
  • Phone: 903-877-7168
  • Fax: 903-877-8355
Mailing address:
  • Phone: 903-877-7168
  • Fax: 903-877-8355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License NumberME129560
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number130324
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number48143
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number130324
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number48143
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME129560
License Number StateFL
# 7
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number130324
License Number StateOH
# 8
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberME129560
License Number StateFL
# 9
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number48143
License Number StateKY
# 10
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberS7462
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: