Provider Demographics
NPI:1285033464
Name:HARRIS, TYSON
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:
Last Name:HARRIS
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 1:5965 S 900 E
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-1720
Mailing Address - Country:US
Mailing Address - Phone:801-263-7138
Mailing Address - Fax:
Practice Address - Street 1:2500 S STATE ST
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3164
Practice Address - Country:US
Practice Address - Phone:385-646-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-14
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9858818-35011041S0200X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool