Provider Demographics
NPI:1730768482
Name:SPOOLER, TYLER RYAN
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:RYAN
Last Name:SPOOLER
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 1:3501 COUNTY ROAD 328
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MO
Mailing Address - Zip Code:63755-8053
Mailing Address - Country:US
Mailing Address - Phone:573-803-9593
Mailing Address - Fax:
Practice Address - Street 1:1417 N MOUNT AUBURN RD STE C
Practice Address - Street 2:
Practice Address - City:CAPE GIRARDEAU
Practice Address - State:MO
Practice Address - Zip Code:63701-2171
Practice Address - Country:US
Practice Address - Phone:919-288-6768
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician