Healthcare Provider Details

I. General information

NPI: 1518185768
Provider Name (Legal Business Name): DONAVAN DANIEL FAUCETTE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2007
Last Update Date: 08/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 E 200 N
LOGAN UT
84321-4034
US

IV. Provider business mailing address

30 W 100 N
HYRUM UT
84319-1214
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-0750
  • Fax:
Mailing address:
  • Phone: 435-764-2386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6729778-3501
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier876000308007
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: