Healthcare Provider Details

I. General information

NPI: 1467252023
Provider Name (Legal Business Name): MR. MICHAEL TYRRELL SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2025
Last Update Date: 03/13/2025
Certification Date: 03/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 MANHASSET TRL
MEDFORD LAKES NJ
08055-1133
US

IV. Provider business mailing address

114 MANHASSET TRL
MEDFORD LAKES NJ
08055-1133
US

V. Phone/Fax

Practice location:
  • Phone: 609-442-8411
  • Fax:
Mailing address:
  • Phone: 609-442-8411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: