Provider Demographics
NPI:1225214828
Name:PATRICK, TYLER (LMFT)
Entity Type:Individual
Prefix:
First Name:TYLER
Middle Name:
Last Name:PATRICK
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:THE
Other - Middle Name:WANDERING
Other - Last Name:THERAPIST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:205 BUCKINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:UT
Mailing Address - Zip Code:84332-9670
Mailing Address - Country:US
Mailing Address - Phone:435-227-5385
Mailing Address - Fax:208-356-4703
Practice Address - Street 1:40 WEST 1250 NORTH
Practice Address - Street 2:3C
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341
Practice Address - Country:US
Practice Address - Phone:208-351-9687
Practice Address - Fax:208-356-4703
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMFTI-3914106H00000X
UT7997802-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807372200Medicaid