Provider Demographics
NPI:1558731869
Name:GEDVILAS, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GEDVILAS
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 1:28W671 GARYS MILL RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1564
Mailing Address - Country:US
Mailing Address - Phone:630-293-9860
Mailing Address - Fax:630-293-9861
Practice Address - Street 1:3933 75TH ST STE 102
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60504-8015
Practice Address - Country:US
Practice Address - Phone:630-293-9860
Practice Address - Fax:630-293-9861
Is Sole Proprietor?:No
Enumeration Date:2015-09-29
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
IL180012829101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health