=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821464298
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLEY MARIE TYLER LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2015
-----------------------------------------------------
Last Update Date | 11/24/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41658 IVY ST STE 117
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92562-9426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-810-8279
-----------------------------------------------------
Fax | 909-614-7882
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41658 IVY ST STE 117
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92562-9426
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-810-8279
-----------------------------------------------------
Fax | 909-614-7882
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 8401
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 109323
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------