Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101Y00000X | Counselor |
NPI | 1003279852 |
---|---|
Provider Name | Tiffany Marie Tyler |
First Address | Vallejo, CA 94590-5962 |
Second Address | Vallejo, CA 94590-4641 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2016 |
Last Update Date | 23/09/2019 |