Provider Demographics
NPI:1275993370
Name:MATHIESEN, TYLER HANS (BCBA)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:HANS
Last Name:MATHIESEN
Suffix:
Gender:M
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1337 HOWE AVE
Mailing Address - Street 2:#107
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-3361
Mailing Address - Country:US
Mailing Address - Phone:916-564-5010
Mailing Address - Fax:
Practice Address - Street 1:1337 HOWE AVE
Practice Address - Street 2:#107
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-3361
Practice Address - Country:US
Practice Address - Phone:916-564-5010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-02
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-18-33110103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst