Basic Information
| Provider Information | |||||||||
| NPI: | 1356633143 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | ANDERSON | ||||||||
| FirstName: | TYLER | ||||||||
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| Credential: | MD, MHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 501 S CHIPETA WAY | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841081222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015817951 | ||||||||
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| Practice Location | |||||||||
| Address1: | 750 N FREEDOM BLVD | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846011677 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013734760 | ||||||||
| FaxNumber: | 8013730639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2011 | ||||||||
| LastUpdateDate: | 06/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | DR.0059856 | CO | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | 6219794-1205 | UT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.