Provider Demographics
NPI:1578361606
Name:VIRGILIO, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:VIRGILIO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 OASIS WAY UNIT 94B
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:24502-1175
Mailing Address - Country:US
Mailing Address - Phone:845-803-2812
Mailing Address - Fax:
Practice Address - Street 1:4000 MURRAY PL
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-5004
Practice Address - Country:US
Practice Address - Phone:845-803-2812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0709026191101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)