Healthcare Provider Details

I. General information

NPI: 1235374984
Provider Name (Legal Business Name): UTAH STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2008
Last Update Date: 08/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6410 OLD MAIN HL
LOGAN UT
84322-6410
US

IV. Provider business mailing address

6410 OLD MAIN HL
LOGAN UT
84322-6410
US

V. Phone/Fax

Practice location:
  • Phone: 435-797-1346
  • Fax: 844-308-5865
Mailing address:
  • Phone: 435-797-1346
  • Fax: 844-308-5865

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: KATHRYN CLEMENTS
Title or Position: FINANCIAL OFFICER
Credential:
Phone: 435-797-5830