Healthcare Provider Details

I. General information

NPI: 1588200752
Provider Name (Legal Business Name): MATTHEW KIRBY M.S., ED.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2019
Last Update Date: 11/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 MEDICAL DR STE D101
BOUNTIFUL UT
84010-8905
US

IV. Provider business mailing address

415 MEDICAL DR STE D101
BOUNTIFUL UT
84010-8905
US

V. Phone/Fax

Practice location:
  • Phone: 801-683-1062
  • Fax: 801-295-5537
Mailing address:
  • Phone: 801-683-1062
  • Fax: 801-295-5537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number533213
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: