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General NPI Number Information
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NPI Number | 1396080917
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Entity Type | Individual
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Provider Name | TYLER BRODERICK MS, LPC
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Gender | Male
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Dates
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Enumeration Date | 12/07/2012
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Last Update Date | 07/09/2019
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Provider Practice Location Address
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Address Line | 521 W LOTT ST
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City | BUFFALO
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State | WY
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Zip | 82834-1642
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Country | US
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Telephone | 307-684-5531
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Fax | 307-684-2912
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Provider Business Mailing Address
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Address Line | 909 LONG DR STE C
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City | SHERIDAN
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State | WY
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Zip | 82801-3282
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Country | US
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Telephone | 307-672-8958
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Fax | 307-672-8950
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | PPC721
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License Number State | WY
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | LPC-1434
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License Number State | WY
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