Provider Demographics
NPI:1174973614
Name:TYSON, SHALANTE A (EDS)
Entity type:Individual
Prefix:
First Name:SHALANTE
Middle Name:A
Last Name:TYSON
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9645 BAYMEADOWS RD APT 637
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7866
Mailing Address - Country:US
Mailing Address - Phone:352-213-9613
Mailing Address - Fax:
Practice Address - Street 1:1009 MAITLAND CENTER COMMONS BLVD STE 2212
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7270
Practice Address - Country:US
Practice Address - Phone:352-213-9613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLIMH15819101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health