Provider Demographics
NPI:1245807411
Name:VARISCO, TYLER JAMES
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:VARISCO
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 1:220 WILKIE ST APT 731
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70506-4095
Mailing Address - Country:US
Mailing Address - Phone:337-280-4807
Mailing Address - Fax:
Practice Address - Street 1:220 WILKIE ST APT 731
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-4095
Practice Address - Country:US
Practice Address - Phone:337-280-4807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-07
Last Update Date:2023-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPLC9964101Y00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor