MEDICARE: TYRA ADALE WILSON

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1790636306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYRA ADALE WILSON

Provider Business Mailing Address
First Line	:	231 W JOHNSON ST APT 204
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-2556
Country	:	US
Telephone Number	:	215-478-5549
Fax Number	:	215-478-5549

Provider Business Practice Location Address
First Line	:	231 W JOHNSON ST APT 204
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19144-2556
Country	:	US
Telephone Number	:	215-478-5549
Fax Number	:	215-478-5549

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

Provider Enumeration Date	:	02/09/2026
Last Update Date	:	02/09/2026

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