Healthcare Provider Details

I. General information

NPI: 1912547704
Provider Name (Legal Business Name): TAWNIELE FITZGERALD MAURER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2020
Last Update Date: 01/17/2023
Certification Date: 01/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 S STATE ST
LINDON UT
84042-1939
US

IV. Provider business mailing address

20 S STATE ST
LINDON UT
84042-1939
US

V. Phone/Fax

Practice location:
  • Phone: 801-441-7144
  • Fax:
Mailing address:
  • Phone: 801-784-9455
  • Fax: 801-441-7144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number128530153904
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: