MEDICARE: DR. TRISTYN TEEL WILKERSON PSY.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1306127253
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TRISTYN TEEL WILKERSON PSY.D.

Provider Business Mailing Address
First Line	:	9300 S REDWOOD RD
Second Line	:	#28-21
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-6607
Country	:	US
Telephone Number	:	206-909-3085
Fax Number	:

Provider Business Practice Location Address
First Line	:	230 S 500 E
Second Line	:	SUITE 100
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-2015
Country	:	US
Telephone Number	:	801-532-1484
Fax Number	:	801-532-1486

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/06/2011
Last Update Date	:	12/29/2017

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