Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225XG0600X | Occupational Therapist - Gerontology | 11796 | CA |
NPI | 1639415458 |
---|---|
Provider Name | Jeffrey Robert Tyler |
First Address | Milwaukie, OR 97222-4628 |
Second Address | Paradise, CA 95969-2823 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/12/2012 |
Last Update Date | 26/12/2012 |