Provider Demographics
NPI:1376161026
Name:O'SULLIVAN, TYLER ROSE (BS ACT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ROSE
Last Name:O'SULLIVAN
Suffix:
Gender:F
Credentials:BS ACT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 HAINES AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-0710
Mailing Address - Country:US
Mailing Address - Phone:605-716-7841
Mailing Address - Fax:
Practice Address - Street 1:1520 HAINES AVE STE 6
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-0710
Practice Address - Country:US
Practice Address - Phone:605-716-7841
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-09
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD110119887193227889Medicaid