Healthcare Provider Details

I. General information

NPI: 1669778122
Provider Name (Legal Business Name): TYLER STICKLE M.ED., LPCC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2011
Last Update Date: 05/19/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 PARKER DR UNIT 2B
LA GRANGE KY
40031-1269
US

IV. Provider business mailing address

1206 BURNT HILL RD
GOSHEN KY
40026-9553
US

V. Phone/Fax

Practice location:
  • Phone: 502-418-3469
  • Fax:
Mailing address:
  • Phone: 502-418-3469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number1243
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code221700000X
TaxonomyArt Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1243
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: