Provider Demographics
NPI:1316795503
Name:SMITH, TYLER CHARLES (LPC, CSAC)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:CHARLES
Last Name:SMITH
Suffix:
Gender:M
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7957 W WIND LAKE RD STE E
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:WI
Mailing Address - Zip Code:53185-2234
Mailing Address - Country:US
Mailing Address - Phone:608-561-8656
Mailing Address - Fax:
Practice Address - Street 1:7957 W WIND LAKE RD STE E
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:WI
Practice Address - Zip Code:53185-2234
Practice Address - Country:US
Practice Address - Phone:608-561-8656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-11
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI17132132101YA0400X
WI10088125101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)