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NPI Code Detail

MEDICARE: TYRAN DEWALT

MEDICARE: TYRAN DEWALT
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
11041C0700XClinical Social Worker260261KY

General Provider Information

NPI Number : 1720366933
Entity Type Code : Individual
Provider Name (Legal Business Name) : TYRAN DEWALT
Provider Business Mailing Address
First Line : 101 W MUHAMMAD ALI BLVD
Second Line :
City : LOUISVILLE
State : KY
Zip : 40202-1423
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 10510 LA GRANGE RD
Second Line :
City : LOUISVILLE
State : KY
Zip : 40223-1277
Country : US
Telephone Number : 502-589-8600
Fax Number : 502-589-8771
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/22/2011
Last Update Date : 12/01/2025

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