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General NPI Number Information
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NPI Number | 1740691542
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Entity Type | Individual
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Provider Name | DR. TYLER FORTMAN
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Gender | Male
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Dates
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Enumeration Date | 05/14/2014
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Last Update Date | 02/14/2017
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Provider Practice Location Address
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Address Line | 3354 N PAULINA ST SUITE 205
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City | CHICAGO
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State | IL
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Zip | 60657-1068
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Country | US
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Telephone | 312-380-9031
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Fax |
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Provider Business Mailing Address
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Address Line | 3354 N PAULINA ST SUITE 205
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City | CHICAGO
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State | IL
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Zip | 60657-1068
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Country | US
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Telephone | 312-380-9031
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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 | 0810004806
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 071008865
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License Number State | IL
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