Healthcare Provider Details

I. General information

NPI: 1235975780
Provider Name (Legal Business Name): TYCHELE A HULETT PTA, LMT, CLT, CCST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2024
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 E WILLIAMS FIELD RD STE E-105
GILBERT AZ
85295-5222
US

IV. Provider business mailing address

91 E PALOMINO DR
GILBERT AZ
85296-2847
US

V. Phone/Fax

Practice location:
  • Phone: 480-282-7124
  • Fax:
Mailing address:
  • Phone: 480-282-7124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-19660
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: