Provider Demographics
NPI:1447472915
Name:TYSON, ANNE MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:TYSON
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SCOTTVILLE
Practice Address - State:MI
Practice Address - Zip Code:49454-1019
Practice Address - Country:US
Practice Address - Phone:616-267-0785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010802511041C0700X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1447472915Medicaid
MI1447472915OtherBCN
MI1447472915OtherBCBS
MI1447472915Medicaid
MI1447472915OtherPRIORITY HEALTH
MI1447472915OtherTRICARE/HEALTHNET