1083709554 NPI number — TYSON RAE FLORA MA LMHC

Table of content: TYSON RAE FLORA MA LMHC (NPI 1083709554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083709554 NPI number — TYSON RAE FLORA MA LMHC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FLORA
Provider First Name:
TYSON
Provider Middle Name:
RAE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MA LMHC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083709554
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6202 CONSTITUTION DR STE D
Provider Second Line Business Mailing Address:
LIFEWORKS COUNSELING & CONSULTING, INC.
Provider Business Mailing Address City Name:
FORT WAYNE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46804-1583
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-432-0066
Provider Business Mailing Address Fax Number:
260-432-8503

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6202 CONSTITUTION DR STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT WAYNE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46804-1583
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-432-0066
Provider Business Practice Location Address Fax Number:
260-432-8503
Provider Enumeration Date:
10/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  39001576A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200912670A , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39001576A . This is a "LICENSE NUMBER" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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