Healthcare Provider Details

I. General information

NPI: 1487562062
Provider Name (Legal Business Name): TYLER ANTHONY GOTTLIEB
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43825 MICHIGAN AVE
CANTON MI
48188-2551
US

IV. Provider business mailing address

7581 KENSINGTON DR
YPSILANTI MI
48197-3174
US

V. Phone/Fax

Practice location:
  • Phone: 734-713-0088
  • Fax: 734-398-5618
Mailing address:
  • Phone: 734-890-9026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number87667
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: