Healthcare Provider Details

I. General information

NPI: 1114515400
Provider Name (Legal Business Name): CARLI AGNES SLADE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2021
Last Update Date: 01/22/2025
Certification Date: 01/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 S 700 E STE 102
AMERICAN FORK UT
84003-2485
US

IV. Provider business mailing address

1051 S 750 W
AMERICAN FORK UT
84003-4541
US

V. Phone/Fax

Practice location:
  • Phone: 801-683-6830
  • Fax:
Mailing address:
  • Phone: 435-633-5712
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9809542-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: