Provider Demographics
NPI:1740840420
Name:SECOR, TYLER W (MS, LPC-IT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:W
Last Name:SECOR
Suffix:
Gender:M
Credentials:MS, LPC-IT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 ELM ST
Mailing Address - Street 2:
Mailing Address - City:WEST BEND
Mailing Address - State:WI
Mailing Address - Zip Code:53095-3229
Mailing Address - Country:US
Mailing Address - Phone:262-338-1661
Mailing Address - Fax:
Practice Address - Street 1:1622 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-3014
Practice Address - Country:US
Practice Address - Phone:262-306-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-16
Last Update Date:2019-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4320-226101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health