Provider Demographics
NPI:1780239178
Name:MACRAE-SMITH, TYLER JONATHON
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JONATHON
Last Name:MACRAE-SMITH
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 1:15605 NE 5TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-3375
Mailing Address - Country:US
Mailing Address - Phone:360-448-8711
Mailing Address - Fax:
Practice Address - Street 1:15605 NE 5TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684-3375
Practice Address - Country:US
Practice Address - Phone:360-448-8711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-03
Last Update Date:2019-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty