Healthcare Provider Details

I. General information

NPI: 1790268423
Provider Name (Legal Business Name): TYLER SCOTT ST. CYR CAGS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2018
Last Update Date: 01/20/2021
Certification Date: 01/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 PEMBROKE ST
PEMBROKE NH
03275-1361
US

IV. Provider business mailing address

267 PEMBROKE ST
PEMBROKE NH
03275-1361
US

V. Phone/Fax

Practice location:
  • Phone: 36-485-5188
  • Fax:
Mailing address:
  • Phone: 603-860-0015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number84937
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: