Provider Demographics
NPI:1376345561
Name:CUILLA, TYLER (LIAC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:CUILLA
Suffix:
Gender:M
Credentials:LIAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9116 W ARDEN LN
Mailing Address - Street 2:
Mailing Address - City:BELLEMONT
Mailing Address - State:AZ
Mailing Address - Zip Code:86015-5021
Mailing Address - Country:US
Mailing Address - Phone:480-212-2946
Mailing Address - Fax:
Practice Address - Street 1:1515 E CEDAR AVE STE E-2
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1646
Practice Address - Country:US
Practice Address - Phone:928-714-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLIAC-155362101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)