Provider Demographics
NPI:1386191674
Name:TYRELL, CARLY (BCBA)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:TYRELL
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4221 WILSHIRE BLVD STE 300A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-3537
Mailing Address - Country:US
Mailing Address - Phone:888-428-3223
Mailing Address - Fax:323-866-1881
Practice Address - Street 1:2100 W ORANGEWOOD AVE STE 150
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868
Practice Address - Country:US
Practice Address - Phone:888-428-3223
Practice Address - Fax:323-866-1881
Is Sole Proprietor?:No
Enumeration Date:2016-09-05
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
CA1-14-9971103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other