Healthcare Provider Details

I. General information

NPI: 1326863135
Provider Name (Legal Business Name): GWENDOLYN TYRIE MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 06/08/2026
Certification Date: 06/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2689 FRANKFORT RD
GEORGETOWN KY
40324-8611
US

IV. Provider business mailing address

2689 FRANKFORT RD
GEORGETOWN KY
40324-8611
US

V. Phone/Fax

Practice location:
  • Phone: 859-537-9779
  • Fax: 502-868-9312
Mailing address:
  • Phone: 859-537-9779
  • Fax: 502-868-9312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: