Provider Demographics
NPI:1487164166
Name:STAFFORD, TYLER
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:STAFFORD
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 1:18726 S WESTERN AVE STE 408
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3858
Mailing Address - Country:US
Mailing Address - Phone:909-583-4040
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:27349 JEFFERSON AVE STE 204
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5612
Practice Address - Country:US
Practice Address - Phone:951-466-3032
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst