Provider Demographics
NPI:1801290168
Name:VASCONCELLOS, TYLER LEE (PSYD)
Entity type:Individual
Prefix:DR
First Name:TYLER LEE
Middle Name:
Last Name:VASCONCELLOS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:DR
Other - First Name:TYLER
Other - Middle Name:
Other - Last Name:VASCONCELLOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PSYD
Mailing Address - Street 1:2712 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1117
Mailing Address - Country:US
Mailing Address - Phone:510-548-8283
Mailing Address - Fax:
Practice Address - Street 1:870 MARKET ST STE 1057
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-2928
Practice Address - Country:US
Practice Address - Phone:415-343-5286
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-15
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY32249103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA942209679Medicaid