Provider Demographics
NPI:1063209344
Name:TRIPP, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:TRIPP
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N HARVEST LN
Mailing Address - Street 2:
Mailing Address - City:WAUSEON
Mailing Address - State:OH
Mailing Address - Zip Code:43567-1467
Mailing Address - Country:US
Mailing Address - Phone:419-356-2674
Mailing Address - Fax:
Practice Address - Street 1:1210 N OTTOKEE ST
Practice Address - Street 2:
Practice Address - City:WAUSEON
Practice Address - State:OH
Practice Address - Zip Code:43567-1906
Practice Address - Country:US
Practice Address - Phone:419-377-4575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities