Healthcare Provider Details

I. General information

NPI: 1750247672
Provider Name (Legal Business Name): LYDIA HARRIS CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2026
Last Update Date: 01/05/2026
Certification Date: 01/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 GOLF COURSE RD STE E
LOGAN UT
84321-5934
US

IV. Provider business mailing address

115 GOLF COURSE RD STE E
LOGAN UT
84321-5934
US

V. Phone/Fax

Practice location:
  • Phone: 435-799-5035
  • Fax:
Mailing address:
  • Phone: 435-779-5303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number142258963502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: