Healthcare Provider Details

I. General information

NPI: 1811713571
Provider Name (Legal Business Name): CARMEN MARIE TYLER PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2024
Last Update Date: 11/26/2024
Certification Date: 11/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 E MAIN ST
DANVILLE IL
61832-5100
US

IV. Provider business mailing address

3209 E MAIN ST
DANVILLE IL
61834-9382
US

V. Phone/Fax

Practice location:
  • Phone: 217-554-5199
  • Fax:
Mailing address:
  • Phone: 904-263-8945
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number20043884A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20043884A
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number20043884A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number20043884A
License Number StateIN
# 5
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number20043884A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: