Provider Demographics
NPI:1558159756
Name:HUMMEL, TYLER KIM
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:KIM
Last Name:HUMMEL
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 1:4020 CIVIC CENTER DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-4173
Mailing Address - Country:US
Mailing Address - Phone:415-491-2525
Mailing Address - Fax:415-444-9662
Practice Address - Street 1:4020 CIVIC CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-4173
Practice Address - Country:US
Practice Address - Phone:415-491-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA04282025100448171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor