MEDICARE: RONNIE TYSON

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	1041C0700X	Clinical Social Worker	6801084070	MI

General Provider Information

NPI Number	:	1790854305
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RONNIE TYSON

Provider Business Mailing Address
First Line	:	529 M L KING AVE
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48502-2002
Country	:	US
Telephone Number	:	810-232-7919
Fax Number	:	810-232-7913

Provider Business Practice Location Address
First Line	:	529 M L KING AVE
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48502-2002
Country	:	US
Telephone Number	:	810-232-7919
Fax Number	:	810-232-7913

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

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	10/22/2013

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Directions to “ RONNIE TYSON ” Practice Location

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