Provider Demographics
NPI:1962856930
Name:TYCKSEN, BRENT ANDREW JR (LCSW)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:ANDREW
Last Name:TYCKSEN
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:173 E 10000 S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:UT
Mailing Address - Zip Code:84653-9253
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5600 NORTH 250 WEST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-226-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10535183-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical