Provider Demographics
NPI:1679144760
Name:SUTHERLAND, TYE
Entity type:Individual
Prefix:
First Name:TYE
Middle Name:
Last Name:SUTHERLAND
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 1:800 ROSS AVE APT 5102
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75202-1830
Mailing Address - Country:US
Mailing Address - Phone:217-294-2116
Mailing Address - Fax:
Practice Address - Street 1:1313 N BELT LINE RD STE 102
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75149-1784
Practice Address - Country:US
Practice Address - Phone:972-289-0691
Practice Address - Fax:972-289-0607
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-08
Last Update Date:2021-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist