Tyler Young Quattlebaum, LPC

Primary specialty

Mental Health CounselorTaxonomy code 101YM0800X

License

P2210005 Issued in AR

Practice address

19 E Mountain St Ste 1
Fayetteville, AR 72701-6067

Phone

(479) 381-0831

NPI assigned

Apr 30, 2018

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1525046400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1665360000000",
    "number": "1366930802",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "19 E MOUNTAIN ST STE 1",
            "city": "FAYETTEVILLE",
            "state": "AR",
            "postal_code": "727016067",
            "telephone_number": "479-381-0831"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "19 E MOUNTAIN ST STE 1",
            "city": "FAYETTEVILLE",
            "state": "AR",
            "postal_code": "727016067",
            "telephone_number": "479-381-0831"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "QUATTLEBAUM",
        "first_name": "TYLER",
        "middle_name": "YOUNG",
        "credential": "LPC",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2018-04-30",
        "last_updated": "2022-10-10",
        "certification_date": "2022-10-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YM0800X",
            "taxonomy_group": "",
            "desc": "Counselor, Mental Health",
            "state": "AR",
            "license": "P2210005",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ARKANSAS BOARD OF EXAMINERS IN COUNSELING AND MARRIAGE & FAMILY THERAPY",
            "identifier": "P2210005",
            "state": "AR"
        }
    ],
    "endpoints": [],
    "other_names": []
}

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• Mental Health Counselor in Fayetteville, AR
• Providers in Fayetteville, AR by specialty
• Mental Health Counselor in Arkansas

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 10, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.