MEDICARE: TYLER T WHITNEY PSYD

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	103G00000X	Clinical Neuropsychologist	PSY202-131	ID

General Provider Information

NPI Number	:	1467670653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER T WHITNEY PSYD

Provider Business Mailing Address
First Line	:	2273 E GALA ST
Second Line	:	SUITE 120
City	:	MERIDIAN
State	:	ID
Zip	:	83642-7289
Country	:	US
Telephone Number	:	208-888-7104
Fax Number	:	208-321-4789

Provider Business Practice Location Address
First Line	:	2273 E GALA ST
Second Line	:	SUITE 120
City	:	MERIDIAN
State	:	ID
Zip	:	83642-7289
Country	:	US
Telephone Number	:	208-888-7104
Fax Number	:	208-321-4789

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

Provider Enumeration Date	:	04/23/2007
Last Update Date	:	07/08/2007

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