Provider Demographics
NPI:1760984413
Name:MITCHELL, TYLER S
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:S
Last Name:MITCHELL
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 1:4312 SLOUGH CT
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-4625
Mailing Address - Country:US
Mailing Address - Phone:916-704-8992
Mailing Address - Fax:
Practice Address - Street 1:4312 SLOUGH CT
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95757-4625
Practice Address - Country:US
Practice Address - Phone:916-704-8992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst