Basic Information
| Provider Information | |||||||||
| NPI: | 1396080917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRODERICK | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | |||||||||
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| Credential: | MS, LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 LONG DR STE C | ||||||||
| Address2: | |||||||||
| City: | SHERIDAN | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828013282 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076728958 | ||||||||
| FaxNumber: | 3076728950 | ||||||||
| Practice Location | |||||||||
| Address1: | 521 W LOTT ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | WY | ||||||||
| PostalCode: | 828341642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3076845531 | ||||||||
| FaxNumber: | 3076842912 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2012 | ||||||||
| LastUpdateDate: | 07/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | PPC721 | WY | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YP2500X | LPC-1434 | WY | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.