Healthcare Provider Details

I. General information

NPI: 1871776146
Provider Name (Legal Business Name): PHYLLIS M TRONRUD M.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: PHYLLIS M WAITE

II. Dates (important events)

Enumeration Date: 12/10/2007
Last Update Date: 05/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 N 2000 W SUITE D
CLINTON UT
84015-8562
US

IV. Provider business mailing address

1407 N 2000 W SUITE D
CLINTON UT
84015-8562
US

V. Phone/Fax

Practice location:
  • Phone: 801-971-5550
  • Fax:
Mailing address:
  • Phone: 801-971-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6818930-6004
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6818930-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: