Healthcare Provider Details

I. General information

NPI: 1609594290
Provider Name (Legal Business Name): MACAYLE STUCKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2022
Last Update Date: 08/19/2022
Certification Date: 08/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 W 1400 N STE A
LOGAN UT
84341-6816
US

IV. Provider business mailing address

685 N 570 E
SMITHFIELD UT
84335-6733
US

V. Phone/Fax

Practice location:
  • Phone: 435-752-5302
  • Fax:
Mailing address:
  • Phone: 435-760-4922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

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: