Provider Demographics
NPI:1316556145
Name:WOODALL, TYLER (LPC-INTERN)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:WOODALL
Suffix:
Gender:M
Credentials:LPC-INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1668 KELLER PARKWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248
Mailing Address - Country:US
Mailing Address - Phone:505-249-1179
Mailing Address - Fax:
Practice Address - Street 1:1668 KELLER PARKWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248
Practice Address - Country:US
Practice Address - Phone:505-249-1179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-11-05
Deactivation Date:2020-10-23
Deactivation Code:
Reactivation Date:2020-11-05
Provider Licenses
StateLicense IDTaxonomies
TX84349101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional