Healthcare Provider Details

I. General information

NPI: 1326780511
Provider Name (Legal Business Name): CHANTAL KOA SSW, CASUDC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 04/08/2024
Certification Date: 04/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 W 820 S UNIT 2
CEDAR CITY UT
84720-3963
US

IV. Provider business mailing address

PO BOX 1131
CEDAR CITY UT
84721-1101
US

V. Phone/Fax

Practice location:
  • Phone: 435-673-2899
  • Fax: 435-359-5159
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number10591268-3503
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10591268-6018
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: