Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103G00000X | Clinical Psychologist | LP6328 | MN |
Y | 103TC0700X | Clinical Psychologist | LP6328 | MN |
N | 103TC1900X | Counseling Psychologist | LP6328 | MN |
N | 103TF0200X | Forensic Psychologist | LP6328 | MN |
NPI | 1104394212 |
---|---|
Provider Name | Dr. Tyler Maxwell Dority |
First Address | Mankato, MN 56001-7783 |
Second Address | Mankato, MN 56001-7783 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/11/2018 |
Last Update Date | 06/11/2018 |