Provider Demographics
NPI:1316106966
Name:COLLEDGE, TANYA (PSYD)
Entity type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:COLLEDGE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 454
Mailing Address - Street 2:
Mailing Address - City:AMERICAN FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84003-0454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1392 W STATE RD
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-5020
Practice Address - Country:US
Practice Address - Phone:801-318-8157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-07
Last Update Date:2008-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5533547-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist