Provider Demographics
NPI:1770332637
Name:TUCKER, KYLER A (MS)
Entity type:Individual
Prefix:
First Name:KYLER
Middle Name:A
Last Name:TUCKER
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 APPLEGROVE ST NE APT B6
Mailing Address - Street 2:
Mailing Address - City:NORTH CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44720-8661
Mailing Address - Country:US
Mailing Address - Phone:330-347-6812
Mailing Address - Fax:
Practice Address - Street 1:20575 CENTER RIDGE RD STE 400
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-3422
Practice Address - Country:US
Practice Address - Phone:440-207-9293
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1-23-64029103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst