Healthcare Provider Details

I. General information

NPI: 1396469136
Provider Name (Legal Business Name): TYLER RYAN LEVY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 09/26/2022
Certification Date: 09/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 ANNAPOLIS RD STE F
ODENTON MD
21113-1387
US

IV. Provider business mailing address

1202 ANNAPOLIS RD STE F
ODENTON MD
21113-1387
US

V. Phone/Fax

Practice location:
  • Phone: 240-296-1370
  • Fax: 410-672-2869
Mailing address:
  • Phone: 240-296-1370
  • Fax: 410-672-2869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: