Provider Demographics
NPI:1639588528
Name:WASHBURN, TYLER (MED, LBSC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:WASHBURN
Suffix:
Gender:M
Credentials:MED, LBSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3822 CHESTNUT HILL ROAD
Mailing Address - Street 2:
Mailing Address - City:COOPERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18036
Mailing Address - Country:US
Mailing Address - Phone:610-597-6239
Mailing Address - Fax:
Practice Address - Street 1:3822 CHESTNUT HILL ROAD
Practice Address - Street 2:
Practice Address - City:COOPERSBURG
Practice Address - State:PA
Practice Address - Zip Code:18036
Practice Address - Country:US
Practice Address - Phone:610-597-6239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002247101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health