Provider Demographics
NPI:1699508515
Name:ROSE, TYLER R
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:R
Last Name:ROSE
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 1:4688 ONTARIO MILLS PKWY
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-5104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4688 ONTARIO MILLS PKWY
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5104
Practice Address - Country:US
Practice Address - Phone:909-476-5747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst