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General NPI Number Information
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NPI Number | 1942519616
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Entity Type | Individual
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Provider Name | GWEN DALE TYSON MS, LPC, NCC
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Gender | Female
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Dates
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Enumeration Date | 09/29/2010
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Last Update Date | 09/29/2010
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Provider Practice Location Address
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Address Line | 57 TREVINO LN APT 11
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City | STARKVILLE
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State | MS
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Zip | 39759-4443
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Country | US
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Telephone | 252-327-0407
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Fax | 662-325-3263
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Provider Business Mailing Address
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Address Line | 2416 CHIPPENHAM CT
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City | WINTERVILLE
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State | NC
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Zip | 28590-9773
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Country | US
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Telephone | 252-327-0407
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Fax | 662-325-3263
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 7368
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License Number State | NC
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