Healthcare Provider Details

I. General information

NPI: 1992055255
Provider Name (Legal Business Name): CAMILLE VAN WAGONER HAWKINS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 11/30/2022
Certification Date: 11/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12587 S FORT ST
DRAPER UT
84020-9382
US

IV. Provider business mailing address

1760 W 4805 S
TAYLORSVILLE UT
84129-1177
US

V. Phone/Fax

Practice location:
  • Phone: 801-203-0244
  • Fax:
Mailing address:
  • Phone: 801-487-0697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number83776633502
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: