Healthcare Provider Details

I. General information

NPI: 1407403041
Provider Name (Legal Business Name): TYLER STRUSOWSKI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2019
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1032 15TH ST NW STE 334
WASHINGTON DC
20005-1502
US

IV. Provider business mailing address

1417 STAPLES ST NE APT 3
WASHINGTON DC
20002-2958
US

V. Phone/Fax

Practice location:
  • Phone: 617-981-4910
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLGPC00402
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: