Healthcare Provider Details

I. General information

NPI: 1538833728
Provider Name (Legal Business Name): KARISSA LORDS KECK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2021
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

476 HERITAGE PARK BLVD STE 220
LAYTON UT
84041-5679
US

IV. Provider business mailing address

476 HERITAGE PARK BLVD STE 220
LAYTON UT
84041-5679
US

V. Phone/Fax

Practice location:
  • Phone: 801-425-0227
  • Fax:
Mailing address:
  • Phone: 801-425-0227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: