Healthcare Provider Details

I. General information

NPI: 1962121442
Provider Name (Legal Business Name): TYLER HENRY EDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2022
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

919 CODY AVE
CODY WY
82414-4115
US

IV. Provider business mailing address

919 CODY AVE
CODY WY
82414-4115
US

V. Phone/Fax

Practice location:
  • Phone: 307-527-6332
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: