Healthcare Provider Details

I. General information

NPI: 1316556145
Provider Name (Legal Business Name): TYLER WOODALL LPC-INTERN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date: 10/23/2020
Reactivation Date: 11/05/2020

III. Provider practice location address

4305 MACARTHUR AVE
DALLAS TX
75209-6511
US

IV. Provider business mailing address

1668 KELLER PARKWAY SUITE 200
KELLER TX
76248
US

V. Phone/Fax

Practice location:
  • Phone: 214-526-4525
  • Fax:
Mailing address:
  • Phone: 505-249-1179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number84349
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: