Healthcare Provider Details

I. General information

NPI: 1083100119
Provider Name (Legal Business Name): TYLEUR JANEL KOTZIAN-UPSHAW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2018
Last Update Date: 07/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17943 SW CORRAL CREEK RD
NEWBERG OR
97132-9310
US

IV. Provider business mailing address

17943 SW CORRAL CREEK RD
NEWBERG OR
97132-9310
US

V. Phone/Fax

Practice location:
  • Phone: 503-860-0109
  • Fax:
Mailing address:
  • Phone: 503-860-0109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: