Basic Information
| Provider Information | |||||||||
| NPI: | 1780993931 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TYLER | ||||||||
| FirstName: | GERALD | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2051 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482081105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139613784 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2051 W GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482081105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3139613784 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2010 | ||||||||
| LastUpdateDate: | 10/05/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 681081892 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.