Healthcare Provider Details

I. General information

NPI: 1033692413
Provider Name (Legal Business Name): TYLER DERUYTER BRASSARD MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 MAIN STREET 8TH FLOOR
SPRINGFIELD MA
01115
US

IV. Provider business mailing address

1500 MAIN STREET 8TH FLOOR
SPRINGFIELD MA
01115
US

V. Phone/Fax

Practice location:
  • Phone: 413-642-1630
  • Fax:
Mailing address:
  • Phone: 413-642-1630
  • Fax:

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: