Basic Information
| Provider Information | |||||||||
| NPI: | 1962888222 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TYLER | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | LPC, CADC III | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1282 3RD ST SPC 96 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971279609 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9712871587 | ||||||||
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| Practice Location | |||||||||
| Address1: | 627 NE EVANS ST | ||||||||
| Address2: | |||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971283923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034347523 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2015 | ||||||||
| LastUpdateDate: | 08/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 15-12-24 | OR | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 101YP2500X | C5515 | OR | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.