Provider Demographics
NPI:1518260280
Name:PEDERSEN, TYLER R (PHD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:R
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 WSC
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84602
Mailing Address - Country:US
Mailing Address - Phone:801-422-3035
Mailing Address - Fax:
Practice Address - Street 1:1500 WSC
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84602
Practice Address - Country:US
Practice Address - Phone:801-830-9155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-17
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4911738-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist