Healthcare Provider Details

I. General information

NPI: 1780785329
Provider Name (Legal Business Name): STAN M FILLMORE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 WEST 200 SOUTH
FARMINGTON UT
84025-1036
US

IV. Provider business mailing address

PO BOX 1036 117 W 200 SO
FARMINGTON UT
84025-1036
US

V. Phone/Fax

Practice location:
  • Phone: 801-451-4843
  • Fax: 801-451-2839
Mailing address:
  • Phone: 801-451-4843
  • Fax: 801-451-2839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1100853501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: