Healthcare Provider Details

I. General information

NPI: 1467340190
Provider Name (Legal Business Name): BROOKS UNDERWOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2025
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4905 S 900 E
MURRAY UT
84117-5703
US

IV. Provider business mailing address

4905 S 900 E
MURRAY UT
84117-5703
US

V. Phone/Fax

Practice location:
  • Phone: 801-869-1095
  • Fax:
Mailing address:
  • Phone: 307-349-1805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number12697241-6006
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: