1225214828 NPI number — TYLER PATRICK LMFT

Table of content: TYLER PATRICK LMFT (NPI 1225214828)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225214828 NPI number — TYLER PATRICK LMFT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATRICK
Provider First Name:
TYLER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMFT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THERAPIST
Provider Other First Name:
THE
Provider Other Middle Name:
WANDERING
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1225214828
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 BUCKINGHAM DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84332-9670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
435-227-5385
Provider Business Mailing Address Fax Number:
208-356-4703

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 WEST 1250 NORTH
Provider Second Line Business Practice Location Address:
3C
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84341
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-351-9687
Provider Business Practice Location Address Fax Number:
208-356-4703
Provider Enumeration Date:
01/14/2008

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: 106H00000X , with the licence number:  MFTI-3914 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X , with the licence number: 7997802-3902 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 807372200 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".




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