Provider Demographics
NPI:1831665256
Name:BECKER, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:BECKER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:TYLER
Other - Middle Name:
Other - Last Name:BECKER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AT
Mailing Address - Street 1:423 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1309
Mailing Address - Country:US
Mailing Address - Phone:414-881-1316
Mailing Address - Fax:
Practice Address - Street 1:N91W15750 FALLS PKWY
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2301
Practice Address - Country:US
Practice Address - Phone:262-532-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1809-392255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer