Provider Demographics
NPI:1275375933
Name:KINGSBURY, TYLER THOMAS
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:THOMAS
Last Name:KINGSBURY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4187 DOGWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-5059
Mailing Address - Country:US
Mailing Address - Phone:941-565-6726
Mailing Address - Fax:
Practice Address - Street 1:13553 ATLANTIC BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-4227
Practice Address - Country:US
Practice Address - Phone:904-420-7030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-12
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician