Healthcare Provider Details

I. General information

NPI: 1780058412
Provider Name (Legal Business Name): BRYAN TYER-WITEK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2015
Last Update Date: 02/20/2024
Certification Date: 02/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 E MAIN RD
MIDDLETOWN RI
02842-4988
US

IV. Provider business mailing address

58 E MAIN RD
MIDDLETOWN RI
02842-4988
US

V. Phone/Fax

Practice location:
  • Phone: 401-608-3322
  • Fax: 401-608-3323
Mailing address:
  • Phone: 401-608-3322
  • Fax: 401-608-3323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: