Healthcare Provider Details

I. General information

NPI: 1124847744
Provider Name (Legal Business Name): KRISTINA MORIAH MACCAUGHAN ACMHC, ATR-P
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTINA LEDEZMA

II. Dates (important events)

Enumeration Date: 10/09/2024
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 E SOUTH UNION AVE
MIDVALE UT
84047-2302
US

IV. Provider business mailing address

105 PARKVIEW TER
PARK CITY UT
84098-5106
US

V. Phone/Fax

Practice location:
  • Phone: 385-346-0031
  • Fax:
Mailing address:
  • Phone: 616-550-3533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14086952-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: