Provider Demographics
NPI:1669070009
Name:TYSON, MAE ROSE (MS CF-SLP)
Entity type:Individual
Prefix:
First Name:MAE
Middle Name:ROSE
Last Name:TYSON
Suffix:
Gender:F
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 GUILFORD RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN BRK
Mailing Address - State:AL
Mailing Address - Zip Code:35223-1217
Mailing Address - Country:US
Mailing Address - Phone:205-936-9893
Mailing Address - Fax:
Practice Address - Street 1:3630 NORTHBROOK DR STE D
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35473-5804
Practice Address - Country:US
Practice Address - Phone:205-246-9345
Practice Address - Fax:949-862-5156
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL200081235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist