=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316106966
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TANYA COLLEDGE PSYD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/07/2008
-----------------------------------------------------
Last Update Date | 06/07/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1392 W STATE RD
-----------------------------------------------------
City | PLEASANT GROVE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84062-5020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-318-8157
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 454
-----------------------------------------------------
City | AMERICAN FORK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84003-0454
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 5533547-2501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------