1306127253 NPI number — DR. TRISTYN TEEL WILKERSON PSY.D.

Table of content: DR. TRISTYN TEEL WILKERSON PSY.D. (NPI 1306127253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306127253 NPI number — DR. TRISTYN TEEL WILKERSON PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILKERSON
Provider First Name:
TRISTYN
Provider Middle Name:
TEEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
TEEL
Provider Other First Name:
TRISTYN
Provider Other Middle Name:
LEIGH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PSY.D
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1306127253
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/29/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9300 S REDWOOD RD
Provider Second Line Business Mailing Address:
#28-21
Provider Business Mailing Address City Name:
WEST JORDAN
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84088-6607
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-909-3085
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
230 S 500 E
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
SALT LAKE CITY
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84102-2015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-532-1484
Provider Business Practice Location Address Fax Number:
801-532-1486
Provider Enumeration Date:
09/06/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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