Provider Demographics
NPI:1003513227
Name:GREEN, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 590
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-0590
Mailing Address - Country:US
Mailing Address - Phone:845-292-5910
Mailing Address - Fax:845-513-2265
Practice Address - Street 1:50 COMMUNITY LN
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NY
Practice Address - Zip Code:12754-2851
Practice Address - Country:US
Practice Address - Phone:845-292-5910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator