Provider Demographics
NPI:1083100119
Name:KOTZIAN-UPSHAW, TYLEUR JANEL
Entity Type:Individual
Prefix:
First Name:TYLEUR
Middle Name:JANEL
Last Name:KOTZIAN-UPSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17943 SW CORRAL CREEK RD
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-9310
Mailing Address - Country:US
Mailing Address - Phone:503-860-0109
Mailing Address - Fax:
Practice Address - Street 1:17943 SW CORRAL CREEK RD
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-9310
Practice Address - Country:US
Practice Address - Phone:503-860-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-01
Last Update Date:2018-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst