Healthcare Provider Details

I. General information

NPI: 1578541330
Provider Name (Legal Business Name): KRISTIE MARIE CHRISTOFFERSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6856 S 700 E
MIDVALE UT
84047-1361
US

IV. Provider business mailing address

6856 S 700 E
MIDVALE UT
84047-1361
US

V. Phone/Fax

Practice location:
  • Phone: 801-743-6100
  • Fax:
Mailing address:
  • Phone: 801-743-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number51906463501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier107035230101
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerINTRMTN. HEALTH CARE
# 2
Identifier885123
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerDESERET MUTUAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: