Provider Demographics
NPI:1215422530
Name:PEMBERTON, TYLER JAMES (QMHS)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:JAMES
Last Name:PEMBERTON
Suffix:
Gender:M
Credentials:QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1751 E LONG ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43203-2045
Mailing Address - Country:US
Mailing Address - Phone:614-493-6009
Mailing Address - Fax:
Practice Address - Street 1:1751 E LONG ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43203-2045
Practice Address - Country:US
Practice Address - Phone:614-493-6009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.20056271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical