MEDICARE: TYLER MONTGOMERY MOUND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1144768326
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER MONTGOMERY MOUND

Provider Business Mailing Address
First Line	:	1323 COPPER AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-4601
Country	:	US
Telephone Number	:	505-910-7016
Fax Number	:

Provider Business Practice Location Address
First Line	:	1323 COPPER AVE NE
Second Line	:
City	:	ALBUQUERQUE
State	:	NM
Zip	:	87106-4601
Country	:	US
Telephone Number	:	505-910-7016
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2017
Last Update Date	:	02/07/2017

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Directions to “ TYLER MONTGOMERY MOUND ” Practice Location

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