Provider Demographics
NPI:1588984835
Name:MANSFIELD, TY R (MMFT, LMFT)
Entity type:Individual
Prefix:MR
First Name:TY
Middle Name:R
Last Name:MANSFIELD
Suffix:
Gender:M
Credentials:MMFT, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 N 1890 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1326
Mailing Address - Country:US
Mailing Address - Phone:801-272-3420
Mailing Address - Fax:
Practice Address - Street 1:667 N 1890 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1326
Practice Address - Country:US
Practice Address - Phone:801-272-3420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-09
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9808828-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist