Healthcare Provider Details

I. General information

NPI: 1194181891
Provider Name (Legal Business Name): TYLER ROBERTSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2016
Last Update Date: 01/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1039 W MASON ST
GREEN BAY WI
54303-1842
US

IV. Provider business mailing address

3031 BAY VIEW DR
GREEN BAY WI
54311-5907
US

V. Phone/Fax

Practice location:
  • Phone: 920-965-7707
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5914
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: