Healthcare Provider Details

I. General information

NPI: 1386938751
Provider Name (Legal Business Name): ALAN RUSHBY CHIDESTER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2011
Last Update Date: 06/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3135 N FAIRFIELD RD STE A
LAYTON UT
84041-8832
US

IV. Provider business mailing address

1435 VINEYARD CIR
BOUNTIFUL UT
84010-8800
US

V. Phone/Fax

Practice location:
  • Phone: 801-771-9099
  • Fax:
Mailing address:
  • Phone: 801-455-4089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5935746-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: