Healthcare Provider Details

I. General information

NPI: 1780358051
Provider Name (Legal Business Name): MATTHEW I STARSIAK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3130 S 400 E
BOUNTIFUL UT
84010-3303
US

IV. Provider business mailing address

75 E FORT UNION BLVD
MIDVALE UT
84047-1531
US

V. Phone/Fax

Practice location:
  • Phone: 385-777-9555
  • Fax:
Mailing address:
  • Phone: 385-777-9555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11457546-6010
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: