Healthcare Provider Details

I. General information

NPI: 1881081628
Provider Name (Legal Business Name): BREANNA SAFSTEN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2015
Last Update Date: 01/08/2024
Certification Date: 12/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75TH MEDICAL GROUP 7321 11TH STREET, BLDG 570
HILL AFB UT
84056
US

IV. Provider business mailing address

75TH MEDICAL GROUP 7321 11TH STREET, BLDG 570
HILL AFB UT
84056
US

V. Phone/Fax

Practice location:
  • Phone: 801-775-4275
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13027697-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: