MEDICARE: TYLEN DAMONEEK KING WHITEHEAD

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	RBT-25-425806	AZ

General Provider Information

NPI Number	:	1184583825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLEN DAMONEEK KING WHITEHEAD

Provider Business Mailing Address
First Line	:	PO BOX 673557
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75267-3557
Country	:	US
Telephone Number	:	317-502-3512
Fax Number	:	855-915-0244

Provider Business Practice Location Address
First Line	:	725 W ELLIOT RD
Second Line	:
City	:	GILBERT
State	:	AZ
Zip	:	85233-5301
Country	:	US
Telephone Number	:	602-767-7942
Fax Number	:	855-915-0244

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

Provider Enumeration Date	:	01/19/2026
Last Update Date	:	01/19/2026

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Directions to “ TYLEN DAMONEEK KING WHITEHEAD ” Practice Location

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