Provider Demographics
NPI:1801395363
Name:KILBANE, TYLER JACK (LPC)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:JACK
Last Name:KILBANE
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 EDGWOOD STREET
Mailing Address - Street 2:APT 1
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003
Mailing Address - Country:US
Mailing Address - Phone:304-238-4074
Mailing Address - Fax:
Practice Address - Street 1:1031 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5709
Practice Address - Country:US
Practice Address - Phone:740-293-4050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2497101YM0800X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2497OtherLICENSE