Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 3808-LCSW | AZ |
NPI | 1003175118 |
---|---|
Provider Name | Ms. Mary Lawrence Tyler |
First Address | Eugene, OR 97401-7638 |
Second Address | Eugene, OR 97401-7638 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 09/05/2012 |
Last Update Date | 09/05/2012 |