Provider Demographics
NPI:1881013266
Name:DAVIS, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:DAVIS
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 1:8607 N 59TH AVE
Mailing Address - Street 2:#C-6
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85302-5433
Mailing Address - Country:US
Mailing Address - Phone:602-753-8040
Mailing Address - Fax:
Practice Address - Street 1:8607 N 59TH AVE
Practice Address - Street 2:#C-6
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85302-5433
Practice Address - Country:US
Practice Address - Phone:602-753-8040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-14
Last Update Date:2014-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4485103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist