Provider Demographics
NPI:1316303381
Name:GROSS-STUART, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:GROSS-STUART
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:PO BOX 1011
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-1011
Mailing Address - Country:US
Mailing Address - Phone:805-478-1689
Mailing Address - Fax:
Practice Address - Street 1:630 W TEFFT ST UNIT 1011
Practice Address - Street 2:
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-7053
Practice Address - Country:US
Practice Address - Phone:805-478-1689
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)