Healthcare Provider Details

I. General information

NPI: 1396640603
Provider Name (Legal Business Name): TYLER CONWAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2026
Last Update Date: 10/08/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2922 CRENSHAW BLVD STE 310
LOS ANGELES CA
90016-4265
US

IV. Provider business mailing address

1123 S GUNLOCK AVE
COMPTON CA
90220-4429
US

V. Phone/Fax

Practice location:
  • Phone: 310-489-1144
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-26-541481
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: