Provider Demographics
NPI:1043961089
Name:MITCHELL, TYLER M
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:M
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 ARTISAN WAY
Mailing Address - Street 2:
Mailing Address - City:FORESTDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02644-1928
Mailing Address - Country:US
Mailing Address - Phone:781-974-6735
Mailing Address - Fax:
Practice Address - Street 1:300 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MA
Practice Address - Zip Code:01757-2806
Practice Address - Country:US
Practice Address - Phone:508-478-0207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-11
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAS08623597103K00000X
222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst