Healthcare Provider Details

I. General information

NPI: 1205549391
Provider Name (Legal Business Name): JOSEPH KOTYNEK CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 01/04/2023
Certification Date: 01/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

382 W MAIN ST
DUCHESNE UT
84021-7761
US

IV. Provider business mailing address

382 W MAIN ST
DUCHESNE UT
84021-7761
US

V. Phone/Fax

Practice location:
  • Phone: 877-701-7600
  • Fax:
Mailing address:
  • Phone: 877-701-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number12912439-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: