Healthcare Provider Details

I. General information

NPI: 1225697162
Provider Name (Legal Business Name): STEPHANIE FAE COWLEY ACMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2019
Last Update Date: 06/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 E FORT UNION BLVD
MIDVALE UT
84047-1531
US

IV. Provider business mailing address

11743 S CURRENT CREEK DR
SOUTH JORDAN UT
84095-7970
US

V. Phone/Fax

Practice location:
  • Phone: 801-508-4767
  • Fax:
Mailing address:
  • Phone: 801-634-9905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10183172
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: