Provider Demographics
NPI:1467670653
Name:WHITNEY, TYLER T (PSYD)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:T
Last Name:WHITNEY
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2273 E GALA ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7289
Mailing Address - Country:US
Mailing Address - Phone:208-888-7104
Mailing Address - Fax:208-321-4789
Practice Address - Street 1:2273 E GALA ST
Practice Address - Street 2:SUITE 120
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7289
Practice Address - Country:US
Practice Address - Phone:208-888-7104
Practice Address - Fax:208-321-4789
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPSY202-131103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist