MEDICARE: MS. JUDY ANN TYSON PH.D.

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	103T00000X	Psychologist	1966	MD

General Provider Information

NPI Number	:	1720086564
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JUDY ANN TYSON PH.D.

Provider Business Mailing Address
First Line	:	8915 SHADY GROVE CT
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20877-1308
Country	:	US
Telephone Number	:	301-963-0060
Fax Number	:	301-258-8858

Provider Business Practice Location Address
First Line	:	8915 SHADY GROVE CT
Second Line	:
City	:	GAITHERSBURG
State	:	MD
Zip	:	20877-1308
Country	:	US
Telephone Number	:	301-963-0060
Fax Number	:	301-258-8858

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

Provider Enumeration Date	:	07/13/2005
Last Update Date	:	03/24/2016

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