Provider Demographics
NPI:1104394212
Name:DORITY, TYLER MAXWELL (PHD, LP)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:MAXWELL
Last Name:DORITY
Suffix:
Gender:M
Credentials:PHD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 CIVIC CENTER PLZ STE 1615
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-7783
Mailing Address - Country:US
Mailing Address - Phone:507-345-4679
Mailing Address - Fax:
Practice Address - Street 1:12 CIVIC CENTER PLZ STE 1615
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-7783
Practice Address - Country:US
Practice Address - Phone:507-345-4679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6328103TC1900X, 103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounselingGroup - Multi-Specialty
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic