Provider Demographics
NPI:1427536481
Name:DOUGLAS, TYLER SHANE (CO60769562)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:SHANE
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:CO60769562
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 217
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942-0217
Mailing Address - Country:US
Mailing Address - Phone:509-457-0990
Mailing Address - Fax:509-454-4548
Practice Address - Street 1:2280 STATE ROUTE 821
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-8302
Practice Address - Country:US
Practice Address - Phone:509-457-0990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO60769562101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)