Provider Demographics
NPI:1255971420
Name:SMITH, TYSON SCOTT (LMFT)
Entity type:Individual
Prefix:
First Name:TYSON
Middle Name:SCOTT
Last Name:SMITH
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2962 W 5500 S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-1214
Mailing Address - Country:US
Mailing Address - Phone:661-747-6973
Mailing Address - Fax:
Practice Address - Street 1:75 E FORT UNION BLVD UNIT 142
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-1531
Practice Address - Country:US
Practice Address - Phone:661-747-6973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11266158-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist