Provider Demographics
NPI:1376024398
Name:LYCKBERG, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:LYCKBERG
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 1:232 BROCK RD
Mailing Address - Street 2:
Mailing Address - City:NEVADA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95959-2902
Mailing Address - Country:US
Mailing Address - Phone:530-575-7221
Mailing Address - Fax:
Practice Address - Street 1:1791 ARASTRADERO RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-1337
Practice Address - Country:US
Practice Address - Phone:800-818-6136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No103T00000XBehavioral Health & Social Service ProvidersPsychologist