Provider Demographics
NPI:1528805298
Name:LASER, TYLER AMOS (MA, LLC)
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:AMOS
Last Name:LASER
Suffix:
Gender:M
Credentials:MA, LLC
Other - Prefix:
Other - First Name:T.
Other - Middle Name:AMOS
Other - Last Name:LASER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, LLC
Mailing Address - Street 1:800 E MILHAM AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49002-1492
Mailing Address - Country:US
Mailing Address - Phone:269-249-7179
Mailing Address - Fax:
Practice Address - Street 1:800 E MILHAM AVE STE 200
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1492
Practice Address - Country:US
Practice Address - Phone:269-249-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023759101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health