Provider Demographics
NPI:1427536481
Name:DOUGLAS, TYLER SHANE (CP61119971)
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:SHANE
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:CP61119971
Other - Prefix:MR
Other - First Name:TYLER
Other - Middle Name:
Other - Last Name:DOUGLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SUDP
Mailing Address - Street 1:401 S 12TH AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3114
Mailing Address - Country:US
Mailing Address - Phone:509-864-1282
Mailing Address - Fax:
Practice Address - Street 1:401 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3114
Practice Address - Country:US
Practice Address - Phone:509-864-1282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP61119971101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)