MEDICARE: TEEJAY GRANT TRIPP DO

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	2084P0800X	Psychiatry Physician	CDR.0000580	CO
2	2084P0800X	Psychiatry Physician	100970	AK
3	2084P0800X	Psychiatry Physician	11583541-1204	UT
4	2084P0804X	Child & Adolescent Psychiatry Physician	005662	AZ
5	2084P0804X	Child & Adolescent Psychiatry Physician	19551	NH
6	2084P0804X	Child & Adolescent Psychiatry Physician	CL0066	NV
7	2084N0400X	Neurology Physician	OS19270	FL

General Provider Information

NPI Number	:	1629308424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TEEJAY GRANT TRIPP DO

Provider Business Mailing Address
First Line	:	3300 N TRIUMPH BLVD STE 500
Second Line	:
City	:	LEHI
State	:	UT
Zip	:	84043-6475
Country	:	US
Telephone Number	:	801-821-2333
Fax Number	:	801-901-1194

Provider Business Practice Location Address
First Line	:	203 FORT WADE RD UNIT 260
Second Line	:
City	:	PONTE VEDRA
State	:	FL
Zip	:	32081-5159
Country	:	US
Telephone Number	:	801-821-2333
Fax Number	:	480-210-0230

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

Provider Enumeration Date	:	12/30/2009
Last Update Date	:	10/07/2024

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Directions to “ TEEJAY GRANT TRIPP DO” Practice Location

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