Healthcare Provider Details

I. General information

NPI: 1467670653
Provider Name (Legal Business Name): TYLER T WHITNEY PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2273 E GALA ST SUITE 120
MERIDIAN ID
83642-7289
US

IV. Provider business mailing address

2273 E GALA ST SUITE 120
MERIDIAN ID
83642-7289
US

V. Phone/Fax

Practice location:
  • Phone: 208-888-7104
  • Fax: 208-321-4789
Mailing address:
  • Phone: 208-888-7104
  • Fax: 208-321-4789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License NumberPSY202-131
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: