Healthcare Provider Details

I. General information

NPI: 1457283681
Provider Name (Legal Business Name): HALEY THEDELL CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2026
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

965 S 100 W STE 106
LOGAN UT
84321-6067
US

IV. Provider business mailing address

965 S 100 W STE 106
LOGAN UT
84321-6067
US

V. Phone/Fax

Practice location:
  • Phone: 435-890-4535
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14287992-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: