Healthcare Provider Details

I. General information

NPI: 1396080917
Provider Name (Legal Business Name): TYLER BRODERICK MS, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2012
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 W LOTT ST
BUFFALO WY
82834-1642
US

IV. Provider business mailing address

909 LONG DR STE C
SHERIDAN WY
82801-3282
US

V. Phone/Fax

Practice location:
  • Phone: 307-684-5531
  • Fax: 307-684-2912
Mailing address:
  • Phone: 307-672-8958
  • Fax: 307-672-8950

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPPC721
License Number StateWY
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC-1434
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: