Basic Information
| Provider Information | |||||||||
| NPI: | 1720634512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TYLER | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | NADINE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 S BROAD ST STE 7 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701196447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043099991 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 200 S BROAD ST STE 7 | ||||||||
| Address2: | |||||||||
| City: | NEW ORLEANS | ||||||||
| State: | LA | ||||||||
| PostalCode: | 701196447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043099991 | ||||||||
| FaxNumber: | 5048210609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2019 | ||||||||
| LastUpdateDate: | 07/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 7521 | LA | N | Behavioral Health & Social Service Providers | Counselor | 171M00000X | PLC7521 | LA | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.