Provider Demographics
NPI:1104433838
Name:HUDDLESTON, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:HUDDLESTON
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 1:1333 1ST ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-3002
Mailing Address - Country:US
Mailing Address - Phone:541-736-2700
Mailing Address - Fax:
Practice Address - Street 1:1333 1ST ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-3002
Practice Address - Country:US
Practice Address - Phone:541-736-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR442184225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist