Healthcare Provider Details

I. General information

NPI: 1508541335
Provider Name (Legal Business Name): HAILEY NICOLE CERISE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2023
Last Update Date: 06/19/2023
Certification Date: 06/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 N MAIN ST STE 104
BOUNTIFUL UT
84010-6115
US

IV. Provider business mailing address

624 S GLENDALE ST
SALT LAKE CITY UT
84104-2433
US

V. Phone/Fax

Practice location:
  • Phone: 801-298-5222
  • Fax:
Mailing address:
  • Phone: 801-330-4675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10831010-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: