Provider Demographics
NPI:1992203657
Name:KEIDEL, TYLER
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:KEIDEL
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 1:12 CRYSTAL PARK RD UNIT 2
Mailing Address - Street 2:
Mailing Address - City:MANITOU SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80829-2183
Mailing Address - Country:US
Mailing Address - Phone:719-726-0231
Mailing Address - Fax:
Practice Address - Street 1:1230 TENDERFOOT HILL RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-7346
Practice Address - Country:US
Practice Address - Phone:719-694-1562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPCC.0019368101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional