Basic Information
| Provider Information | |||||||||
| NPI: | 1700486586 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BOULANGER | ||||||||
| FirstName: | TYLER | ||||||||
| MiddleName: | JAMES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4212 SE DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972061680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380705 | ||||||||
| FaxNumber: | 5032367166 | ||||||||
| Practice Location | |||||||||
| Address1: | 4212 SE DIVISION ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972061680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5032380705 | ||||||||
| FaxNumber: | 5032367166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2020 | ||||||||
| LastUpdateDate: | 08/21/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC1900X | Y | Behavioral Health & Social Service Providers | Psychologist | Counseling |
No ID Information.