Healthcare Provider Details

I. General information

NPI: 1477098937
Provider Name (Legal Business Name): MIRIAH IKEMIYASHIRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2016
Last Update Date: 12/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E 4500 S STE 300
MURRAY UT
84107-4502
US

IV. Provider business mailing address

12993 S SHAWNEE DR
RIVERTON UT
84096-7805
US

V. Phone/Fax

Practice location:
  • Phone: 435-760-9020
  • Fax:
Mailing address:
  • Phone: 435-760-9020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: