Provider Demographics
NPI:1316307887
Name:VENJOHN, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:VENJOHN
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 1:4118 SELKIRK RD
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-8291
Mailing Address - Country:US
Mailing Address - Phone:701-426-0742
Mailing Address - Fax:
Practice Address - Street 1:4118 SELKIRK RD
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-8291
Practice Address - Country:US
Practice Address - Phone:701-426-0742
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1451225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist