Healthcare Provider Details

I. General information

NPI: 1962888222
Provider Name (Legal Business Name): ANDREA J TYLER LPC, CADC III
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2015
Last Update Date: 08/02/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 NE EVANS ST
MCMINNVILLE OR
97128-3923
US

IV. Provider business mailing address

1282 3RD ST SPC 96
LAFAYETTE OR
97127-9609
US

V. Phone/Fax

Practice location:
  • Phone: 503-434-7523
  • Fax:
Mailing address:
  • Phone: 971-287-1587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number15-12-24
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC5515
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: