Provider Demographics
NPI:1669778122
Name:STICKLE, TYLER (MED, LPCC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:STICKLE
Suffix:
Gender:M
Credentials:MED, LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1206 BURNT HILL RD
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:KY
Mailing Address - Zip Code:40026-9553
Mailing Address - Country:US
Mailing Address - Phone:502-418-3469
Mailing Address - Fax:
Practice Address - Street 1:207 PARKER DR UNIT 2B
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:KY
Practice Address - Zip Code:40031-1269
Practice Address - Country:US
Practice Address - Phone:502-418-3469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1243101YP2500X, 101YM0800X
221700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY600863657OtherMAGELLAN HEALTH