Provider Demographics
NPI:1801411566
Name:DALY, TYLER GRANT
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:GRANT
Last Name:DALY
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 1:3420 COUNCIL ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3656
Mailing Address - Country:US
Mailing Address - Phone:323-823-0343
Mailing Address - Fax:
Practice Address - Street 1:4221 WILSHIRE BLVD # 290
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-3512
Practice Address - Country:US
Practice Address - Phone:424-646-3729
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-09
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112829101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health