Provider Demographics
NPI:1467129890
Name:BROWN, TYLER ROBERT (PHD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:ROBERT
Last Name:BROWN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 DOCTORS CT
Mailing Address - Street 2:
Mailing Address - City:OSHKOSH
Mailing Address - State:WI
Mailing Address - Zip Code:54901-2065
Mailing Address - Country:US
Mailing Address - Phone:920-303-5100
Mailing Address - Fax:920-303-5151
Practice Address - Street 1:414 DOCTORS CT
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-2065
Practice Address - Country:US
Practice Address - Phone:920-303-5100
Practice Address - Fax:920-303-5151
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4026-057103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100184112Medicaid