Basic Information
| Provider Information | |||||||||
| NPI: | 1750666830 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TYRRELL-BAKER | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PSYSHOLOGIST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 220 HERALD PLACE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132025002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154727363 | ||||||||
| FaxNumber: | 3157012368 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 HERALD PLACE | ||||||||
| Address2: | 4TH FLOOR | ||||||||
| City: | SYRACUSE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 132025002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3154727363 | ||||||||
| FaxNumber: | 3157012368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2011 | ||||||||
| LastUpdateDate: | 10/21/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 014483 | NY | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1235184235 | 01 | GRP NPI | OTHER | BA1047 | 01 | GRP MEDICARE | OTHER | 02994838 | 01 | NY | GRP MEDICAID | OTHER |