Healthcare Provider Details

I. General information

NPI: 1760763676
Provider Name (Legal Business Name): KAREN CLARK COULAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

94 E PAGES LN A
CENTERVILLE UT
84014-2216
US

IV. Provider business mailing address

460 N 1250 E
BOUNTIFUL UT
84010-2700
US

V. Phone/Fax

Practice location:
  • Phone: 801-294-0578
  • Fax: 801-298-2147
Mailing address:
  • Phone: 801-294-0320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: