Provider Demographics
NPI:1356498919
Name:TYLL, MARY DOLORES (PHD ABPP MSCP)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:DOLORES
Last Name:TYLL
Suffix:
Gender:
Credentials:PHD ABPP MSCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 MARR ST
Mailing Address - Street 2:
Mailing Address - City:TRUTH OR CONSEQUENCES
Mailing Address - State:NM
Mailing Address - Zip Code:87901-3335
Mailing Address - Country:US
Mailing Address - Phone:915-929-9362
Mailing Address - Fax:
Practice Address - Street 1:509 MARR ST
Practice Address - Street 2:
Practice Address - City:TRUTH OR CONSEQUENCES
Practice Address - State:NM
Practice Address - Zip Code:87901-3335
Practice Address - Country:US
Practice Address - Phone:915-929-9362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-05
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1310103TC0700X
NMPSY-RXP0061103TP0016X
FLPY 6142103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TP0016XBehavioral Health & Social Service ProvidersPsychologistPrescribing (Medical)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMPSY-RXP0061OtherPRESCRIBING PSYCHOLOGIST
NM1310OtherNM BOARD OF PSYCHOLOGIST EXAMINERS-PSYCHOLOGY
FLPY6142OtherFLORIDA DEPARTMENT OF HEALTH DIVISION OF MEDICAL QUALITY ASSURANCE-PSYCHOLOGY