Provider Demographics
NPI:1316417066
Name:LAMOUREUX, TYLER R
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:R
Last Name:LAMOUREUX
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 1:3366 ROUTE 5A
Mailing Address - Street 2:
Mailing Address - City:WEST CHARLESTON
Mailing Address - State:VT
Mailing Address - Zip Code:05872-9631
Mailing Address - Country:US
Mailing Address - Phone:802-323-4480
Mailing Address - Fax:
Practice Address - Street 1:3366 ROUTE 5A
Practice Address - Street 2:
Practice Address - City:WEST CHARLESTON
Practice Address - State:VT
Practice Address - Zip Code:05872-9631
Practice Address - Country:US
Practice Address - Phone:802-323-4480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT390200000X, 2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program