Provider Demographics
NPI:1750753539
Name:LENNON, TYLER (CADC, BS)
Entity type:Individual
Prefix:MR
First Name:TYLER
Middle Name:
Last Name:LENNON
Suffix:
Gender:M
Credentials:CADC, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1630 11TH ST
Mailing Address - Street 2:
Mailing Address - City:MANSON
Mailing Address - State:IA
Mailing Address - Zip Code:50563-5026
Mailing Address - Country:US
Mailing Address - Phone:515-571-8522
Mailing Address - Fax:
Practice Address - Street 1:726 S 17TH ST
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5344
Practice Address - Country:US
Practice Address - Phone:515-576-7261
Practice Address - Fax:515-955-7628
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-20
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA15084101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)