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General NPI Number Information
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NPI Number | 1356498919
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Entity Type | Individual
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Provider Name | MARY DOLORES TYLL PHD ABPP MSCP
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Gender | Female
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Dates
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Enumeration Date | 01/05/2007
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Last Update Date | 04/17/2025
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Provider Practice Location Address
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Address Line | 509 MARR ST
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City | TRUTH OR CONSEQUENCES
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State | NM
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Zip | 87901-3335
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Country | US
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Telephone | 915-929-9362
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Fax |
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Provider Business Mailing Address
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Address Line | 509 MARR ST
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City | TRUTH OR CONSEQUENCES
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State | NM
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Zip | 87901-3335
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Country | US
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Telephone | 915-929-9362
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 1310
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 103TP0016X
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Taxonomy Name | Prescribing (Medical) Psychologist
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License Number | PSY-RXP0061
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License Number State | NM
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Taxonomy #3
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | PY 6142
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License Number State | FL
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