Healthcare Provider Details

I. General information

NPI: 1689155038
Provider Name (Legal Business Name): ALYCIA TYLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2018
Last Update Date: 08/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9424 256TH ST N
PORT BYRON IL
61275-9727
US

IV. Provider business mailing address

4217 53RD AVE
BETTENDORF IA
52722-1225
US

V. Phone/Fax

Practice location:
  • Phone: 309-523-3186
  • Fax:
Mailing address:
  • Phone: 630-402-7099
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number242.004812
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: