Provider Demographics
NPI:1780058412
Name:TYER-WITEK, BRYAN
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:TYER-WITEK
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 1:58 E MAIN RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-4988
Mailing Address - Country:US
Mailing Address - Phone:401-608-3322
Mailing Address - Fax:401-608-3323
Practice Address - Street 1:58 E MAIN RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-4988
Practice Address - Country:US
Practice Address - Phone:401-608-3322
Practice Address - Fax:401-608-3323
Is Sole Proprietor?:No
Enumeration Date:2015-11-18
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1780058412Medicaid