Provider Demographics
NPI:1184630063
Name:TULLOCH, TY LOWELL (LPC, LSOTP)
Entity Type:Individual
Prefix:MR
First Name:TY
Middle Name:LOWELL
Last Name:TULLOCH
Suffix:
Gender:M
Credentials:LPC, LSOTP
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 204
Mailing Address - Street 2:616 NORTH MAIN STREET
Mailing Address - City:TEMPLE
Mailing Address - State:TX
Mailing Address - Zip Code:76503-0204
Mailing Address - Country:US
Mailing Address - Phone:254-773-9984
Mailing Address - Fax:254-773-7902
Practice Address - Street 1:616 N MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76501-3249
Practice Address - Country:US
Practice Address - Phone:254-773-9984
Practice Address - Fax:254-773-7902
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16848101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor