Provider Demographics
NPI:1013455823
Name:BUCKHOUT, TYLER SMITH (LICSW)
Entity Type:Individual
Prefix:MR
First Name:TYLER
Middle Name:SMITH
Last Name:BUCKHOUT
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 HAYNES ST UNIT 101
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-4952
Mailing Address - Country:US
Mailing Address - Phone:978-387-4404
Mailing Address - Fax:
Practice Address - Street 1:294 BOWDOIN ST
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-1814
Practice Address - Country:US
Practice Address - Phone:617-388-7885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1273771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical