Provider Demographics
NPI:1740760834
Name:HERRICK, TYSON L (PT)
Entity Type:Individual
Prefix:
First Name:TYSON
Middle Name:L
Last Name:HERRICK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 E STATE RD
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-2151
Mailing Address - Country:US
Mailing Address - Phone:801-492-6577
Mailing Address - Fax:801-492-6579
Practice Address - Street 1:1275 S 800 E
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84097-7232
Practice Address - Country:US
Practice Address - Phone:801-224-7667
Practice Address - Fax:801-616-4098
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10861853-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist