Healthcare Provider Details

I. General information

NPI: 1427590686
Provider Name (Legal Business Name): KRYSTAL DAGLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 04/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11038 HIGHLAND BLVD STE 300
HIGHLAND UT
84003-3788
US

IV. Provider business mailing address

11038 HIGHLAND BLVD STE 300
HIGHLAND UT
84003-3788
US

V. Phone/Fax

Practice location:
  • Phone: 801-899-9041
  • Fax: 320-204-6481
Mailing address:
  • Phone: 801-899-9041
  • Fax: 320-204-6481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number8199455-3902
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: