Basic Information
Provider Information | |||||||||
NPI: | 1497131627 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | HEBERT | ||||||||
FirstName: | TYLER | ||||||||
MiddleName: | PAUL | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PH.D., LMFT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 901 S VIENNA ST | ||||||||
Address2: |   | ||||||||
City: | RUSTON | ||||||||
State: | LA | ||||||||
PostalCode: | 712705829 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3182555020 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3501 PATRICK ST | ||||||||
Address2: |   | ||||||||
City: | LAKE CHARLES | ||||||||
State: | LA | ||||||||
PostalCode: | 706051717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3372637119 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2015 | ||||||||
LastUpdateDate: | 08/11/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFT 1171 | LA | Y |   | Behavioral Health & Social Service Providers | Marriage & Family Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 600720479 | 05 | LA |   | MEDICAID |