Provider Demographics
NPI:1306679220
Name:WILLSON, TYLER GRANT
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:GRANT
Last Name:WILLSON
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 1:1252 BERRYHILL CT
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-2093
Mailing Address - Country:US
Mailing Address - Phone:803-984-9610
Mailing Address - Fax:
Practice Address - Street 1:1547 CHERRY RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2616
Practice Address - Country:US
Practice Address - Phone:803-792-0771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician