Healthcare Provider Details

I. General information

NPI: 1548996275
Provider Name (Legal Business Name): TYLER BASHAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2022
Last Update Date: 07/26/2022
Certification Date: 07/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 N MICHIGAN AVE
CHICAGO IL
60601-3901
US

IV. Provider business mailing address

3146 N SOUTHPORT AVE
CHICAGO IL
60657-9851
US

V. Phone/Fax

Practice location:
  • Phone: 312-815-9660
  • Fax:
Mailing address:
  • Phone: 812-207-8712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: