1427793413 NPI number — KAYLA RHIANNON TYLER SUD COUNSELOR

Table of content: KAYLA RHIANNON TYLER SUD COUNSELOR (NPI 1427793413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427793413 NPI number — KAYLA RHIANNON TYLER SUD COUNSELOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TYLER
Provider First Name:
KAYLA
Provider Middle Name:
RHIANNON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
SUD COUNSELOR
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:
1427793413
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1030 CALIFORNIA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MODESTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95351-2102
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
209-284-0970
Provider Business Mailing Address Fax Number:
209-284-0971

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1405 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MODESTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95354-0748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-284-0970
Provider Business Practice Location Address Fax Number:
209-284-0971
Provider Enumeration Date:
05/03/2022

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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