Healthcare Provider Details

I. General information

NPI: 1881043487
Provider Name (Legal Business Name): SOUTH DAVIS PSYCHOLOGICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2016
Last Update Date: 06/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 N EAST PROMONTORY STE 200
FARMINGTON UT
84025-2950
US

IV. Provider business mailing address

1155 LAKEVIEW DR
BOUNTIFUL UT
84010-1909
US

V. Phone/Fax

Practice location:
  • Phone: 801-934-3373
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. JONATHAN AHERN
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PH.D.
Phone: 801-934-3373