Provider Demographics
NPI:1124335641
Name:THAYNE, TIMMY RYAN (MFT)
Entity type:Individual
Prefix:DR
First Name:TIMMY
Middle Name:RYAN
Last Name:THAYNE
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 E MAIN ST # 215
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-2293
Mailing Address - Country:US
Mailing Address - Phone:801-768-1441
Mailing Address - Fax:801-705-0333
Practice Address - Street 1:256 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-1476
Practice Address - Country:US
Practice Address - Phone:801-768-1441
Practice Address - Fax:801-705-0333
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2010-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT368382-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist