Healthcare Provider Details

I. General information

NPI: 1083531842
Provider Name (Legal Business Name): MICHAEL TYLER ALLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2026
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1636 LEXINGTON AVE
MANSFIELD OH
44907-2907
US

IV. Provider business mailing address

1636 LEXINGTON AVE
MANSFIELD OH
44907-2907
US

V. Phone/Fax

Practice location:
  • Phone: 419-709-8176
  • Fax:
Mailing address:
  • Phone: 419-709-8176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: