MEDICARE: MARQUIA RENEE TYLER LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	0904008826	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0904008826	OTHER	VA	STATE LICENSE

General Provider Information

NPI Number	:	1558802892
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARQUIA RENEE TYLER LCSW

Provider Business Mailing Address
First Line	:	8513 OAKVIEW AVE
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23228-2818
Country	:	US
Telephone Number	:	804-264-1659
Fax Number	:	888-868-5899

Provider Business Practice Location Address
First Line	:	8513 OAKVIEW AVE
Second Line	:
City	:	HENRICO
State	:	VA
Zip	:	23228-2818
Country	:	US
Telephone Number	:	804-264-1659
Fax Number	:	888-868-5899

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/20/2017
Last Update Date	:	03/20/2017

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