Provider Demographics
NPI:1932719093
Name:KING, TYLER SCOTT
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:SCOTT
Last Name:KING
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:N/A
Other - Middle Name:
Other - Last Name:N/A
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:4 JUNIPER LN
Mailing Address - Street 2:
Mailing Address - City:CULLODEN
Mailing Address - State:WV
Mailing Address - Zip Code:25510-9192
Mailing Address - Country:US
Mailing Address - Phone:304-590-0454
Mailing Address - Fax:
Practice Address - Street 1:716 LEE ST E STE 201
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1707
Practice Address - Country:US
Practice Address - Phone:304-807-6227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSW042014669104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker