MEDICARE: TYLISSA TATE LCSW

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	LCSW-22252	AZ

General Provider Information

NPI Number	:	1942168109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLISSA TATE LCSW

Provider Business Mailing Address
First Line	:	14640 S 24TH WAY
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-9054
Country	:	US
Telephone Number	:	480-246-7108
Fax Number	:

Provider Business Practice Location Address
First Line	:	14640 S 24TH WAY
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85048-9054
Country	:	US
Telephone Number	:	480-246-7108
Fax Number	:

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

Provider Enumeration Date	:	01/14/2026
Last Update Date	:	01/14/2026

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