Healthcare Provider Details

I. General information

NPI: 1356498919
Provider Name (Legal Business Name): MARY DOLORES TYLL PHD ABPP MSCP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 04/17/2025
Certification Date: 04/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 MARR ST
TRUTH OR CONSEQUENCES NM
87901-3335
US

IV. Provider business mailing address

509 MARR ST
TRUTH OR CONSEQUENCES NM
87901-3335
US

V. Phone/Fax

Practice location:
  • Phone: 915-929-9362
  • Fax:
Mailing address:
  • Phone: 915-929-9362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1310
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberPSY-RXP0061
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPY 6142
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: