1720622491 NPI number — MRS. TYSHEENA PATRICE CONYERS LCSW

Table of content: MRS. TYSHEENA PATRICE CONYERS LCSW (NPI 1720622491)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720622491 NPI number — MRS. TYSHEENA PATRICE CONYERS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONYERS
Provider First Name:
TYSHEENA
Provider Middle Name:
PATRICE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
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:
1720622491
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19 WINDY WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SMYRNA
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19977-1846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
419-559-9730
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25 S OLD BALTIMORE PIKE STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHRISTIANA
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19702-1540
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-266-6200
Provider Business Practice Location Address Fax Number:
302-266-6212
Provider Enumeration Date:
11/05/2019

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: 1041C0700X , with the licence number:  Q1-0001723 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: Q1-0001723 . This is a "DELAWARE BOARD OF SOCIAL WORK EXAMINERS" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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