Healthcare Provider Details

I. General information

NPI: 1598427551
Provider Name (Legal Business Name): TYLER THURMAN YEAGLEY SUDCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2021
Last Update Date: 05/23/2025
Certification Date: 05/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 I ST
SACRAMENTO CA
95816-3841
US

IV. Provider business mailing address

PO BOX 707
WALNUT GROVE CA
95690-0707
US

V. Phone/Fax

Practice location:
  • Phone: 916-860-1888
  • Fax:
Mailing address:
  • Phone: 916-436-1707
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12144
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: