Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 103TC2200X | Clinical Child & Adolescent Psychologist | S89535642 | MA |
NPI | 1013455823 |
---|---|
Provider Name | Mr. Tyler Smith Buckhout |
First Address | Worcester, MA 01604-1730 |
Second Address | Lexington, MA 02420-4436 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 01/02/2017 |
Last Update Date | 01/02/2017 |