Healthcare Provider Details

I. General information

NPI: 1053759985
Provider Name (Legal Business Name): ASHLEY CAROLINA BROG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY CAROLINA GRAHAM

II. Dates (important events)

Enumeration Date: 06/13/2013
Last Update Date: 05/13/2024
Certification Date: 05/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 W 100 S STE 200
LOGAN UT
84321-5842
US

IV. Provider business mailing address

1934 N 1200 E
NORTH LOGAN UT
84341-2006
US

V. Phone/Fax

Practice location:
  • Phone: 801-822-2109
  • Fax:
Mailing address:
  • Phone: 801-822-2109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8572468-3502
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8572468-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: