Healthcare Provider Details

I. General information

NPI: 1457879157
Provider Name (Legal Business Name): TYLER D ZIPFEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 09/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 MARKET AVE
EAST SAINT LOUIS IL
62201-1811
US

IV. Provider business mailing address

PO BOX 6152
EAST SAINT LOUIS IL
62202-6152
US

V. Phone/Fax

Practice location:
  • Phone: 618-875-9355
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number149.018911
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: