Provider Demographics
NPI:1417713900
Name:KNAUTZ, TYLER JUSTISE
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JUSTISE
Last Name:KNAUTZ
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 1:3425 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BAKER CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97814-1340
Mailing Address - Country:US
Mailing Address - Phone:541-523-7400
Mailing Address - Fax:541-523-4927
Practice Address - Street 1:3600 13TH ST
Practice Address - Street 2:
Practice Address - City:BAKER CITY
Practice Address - State:OR
Practice Address - Zip Code:97814-1346
Practice Address - Country:US
Practice Address - Phone:541-523-9559
Practice Address - Fax:541-523-8067
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-22
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPENDING101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORB311170OtherODL