Healthcare Provider Details

I. General information

NPI: 1669799912
Provider Name (Legal Business Name): REVA C ROSENBAND M.S., LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 04/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1755 N 200 E
LOGAN UT
84341-1915
US

IV. Provider business mailing address

1755 N 200 E
LOGAN UT
84341-1915
US

V. Phone/Fax

Practice location:
  • Phone: 435-753-6245
  • Fax: 435-787-9320
Mailing address:
  • Phone: 435-753-6245
  • Fax: 435-787-9320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number6654227-3902
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number6654227-3902
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: