Provider Demographics
NPI:1760253058
Name:TYLER BUCKHOUT, LICSW, LLC
Entity Type:Organization
Organization Name:TYLER BUCKHOUT, LICSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:S
Authorized Official - Last Name:BUCKHOUT
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:978-387-4404
Mailing Address - Street 1:14 HAYNES ST UNIT 101
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-4952
Mailing Address - Country:US
Mailing Address - Phone:978-387-4404
Mailing Address - Fax:
Practice Address - Street 1:14 HAYNES ST UNIT 101
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-4952
Practice Address - Country:US
Practice Address - Phone:617-863-0096
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health