Provider Demographics
NPI:1548087505
Name:RUSSELL, TYLA
Entity type:Individual
Prefix:
First Name:TYLA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TYLA
Other - Middle Name:
Other - Last Name:BERRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:22668 E WEAVER DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-7000
Mailing Address - Country:US
Mailing Address - Phone:720-254-2569
Mailing Address - Fax:
Practice Address - Street 1:13721 E RICE PL
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80015-1062
Practice Address - Country:US
Practice Address - Phone:720-524-7648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician