MEDICARE: KAREN MICHELLE TYSON LADC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	1305	CT

General Provider Information

NPI Number	:	1588146062
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAREN MICHELLE TYSON LADC

Provider Business Mailing Address
First Line	:	PO BOX 7720
Second Line	:	CREDENTIALING SPECIALIST
City	:	NEW HAVEN
State	:	CT
Zip	:	06519-0720
Country	:	US
Telephone Number	:	203-503-3174
Fax Number	:	203-503-3183

Provider Business Practice Location Address
First Line	:	62 GRANT STREET
Second Line	:	GRANT STREET PARTNERSHIP
City	:	NEW HAVEN
State	:	CT
Zip	:	06519-3456
Country	:	US
Telephone Number	:	203-503-3350
Fax Number	:	203-503-3370

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2018
Last Update Date	:	08/31/2018

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