Healthcare Provider Details

I. General information

NPI: 1154642502
Provider Name (Legal Business Name): MS. TINA ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2010
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2250 N 1700 W
LAYTON UT
84041-1140
US

IV. Provider business mailing address

769 COWLEY ST
LAYTON UT
84041-2211
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-7060
  • Fax:
Mailing address:
  • Phone: 801-773-7060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11903573-3502
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: