Provider Demographics
NPI:1720869100
Name:PRINCE, ROBERT TYLER (MS, CGC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:TYLER
Last Name:PRINCE
Suffix:
Gender:M
Credentials:MS, CGC
Other - Prefix:
Other - First Name:TYLER
Other - Middle Name:
Other - Last Name:PRINCE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS, CGC
Mailing Address - Street 1:44555 WOODWARD AVE STE 404
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5036
Mailing Address - Country:US
Mailing Address - Phone:947-232-7112
Mailing Address - Fax:248-858-3648
Practice Address - Street 1:44555 WOODWARD AVE STE 404
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5036
Practice Address - Country:US
Practice Address - Phone:947-232-7112
Practice Address - Fax:248-858-3648
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7201000255170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS