Provider Demographics
NPI:1811673643
Name:SLOCUM, TYLER CHARLES (ATC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:CHARLES
Last Name:SLOCUM
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8938 CENTER POINTE DR
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-1431
Mailing Address - Country:US
Mailing Address - Phone:315-663-5880
Mailing Address - Fax:
Practice Address - Street 1:5823 WIDEWATERS PKWY
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-3084
Practice Address - Country:US
Practice Address - Phone:315-418-4007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0030112255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer