Provider Demographics
NPI:1790443331
Name:JOHNSON, TYLER (PEER SUPPORT)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:M
Credentials:PEER SUPPORT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MALTA
Mailing Address - State:OH
Mailing Address - Zip Code:43758-9019
Mailing Address - Country:US
Mailing Address - Phone:740-651-7836
Mailing Address - Fax:
Practice Address - Street 1:4977 NORTHCUTT PL
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-3839
Practice Address - Country:US
Practice Address - Phone:800-829-5461
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-01
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPS005364175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist