MEDICARE: MS. MARY E TYLER LMSW

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	6802079451	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1780805051
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY E TYLER LMSW

Provider Business Mailing Address
First Line	:	2700 BAKER ST FL 3
Second Line	:
City	:	MUSKEGON HEIGHTS
State	:	MI
Zip	:	49444-2157
Country	:	US
Telephone Number	:	231-737-1335
Fax Number	:

Provider Business Practice Location Address
First Line	:	2700 BAKER ST
Second Line	:
City	:	MUSKEGON HEIGHTS
State	:	MI
Zip	:	49444-2157
Country	:	US
Telephone Number	:	231-737-1335
Fax Number	:

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

Provider Enumeration Date	:	05/02/2007
Last Update Date	:	04/09/2020

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