Healthcare Provider Details

I. General information

NPI: 1992775415
Provider Name (Legal Business Name): FAN LEE KWAN MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7434 S STATE ST
MIDVALE UT
84047-2014
US

IV. Provider business mailing address

6294 TERRACE RIDGE DR
WEST VALLEY CITY UT
84128-5604
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-4423
  • Fax:
Mailing address:
  • Phone: 801-964-5185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number369290-3501
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier107018309101
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerU006
# 2
IdentifierQ10178
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerICAR
# 3
Identifier942938348KW1
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerU003
# 4
Identifier802652
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerU002

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: