Basic Information
Provider Information | |||||||||
NPI: | 1831665256 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BECKER | ||||||||
FirstName: | TYLER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BECKER | ||||||||
OtherFirstName: | TYLER | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | MR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | AT | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 423 GREEN BAY RD | ||||||||
Address2: |   | ||||||||
City: | THIENSVILLE | ||||||||
State: | WI | ||||||||
PostalCode: | 530921309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4148811316 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | N91W15750 FALLS PKWY | ||||||||
Address2: |   | ||||||||
City: | MENOMONEE FALLS | ||||||||
State: | WI | ||||||||
PostalCode: | 530512301 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2625321100 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/24/2018 | ||||||||
LastUpdateDate: | 10/24/2018 | ||||||||
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 | 2255A2300X | 1809-39 | WI | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.