Healthcare Provider Details

I. General information

NPI: 1528834439
Provider Name (Legal Business Name): SUZANNE A VANWAGONER LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2023
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

488 E WINCHESTER ST STE 240
MURRAY UT
84107-7590
US

IV. Provider business mailing address

4465 S 900 E STE 150
MILLCREEK UT
84124-3944
US

V. Phone/Fax

Practice location:
  • Phone: 435-248-2089
  • Fax: 801-207-5104
Mailing address:
  • Phone: 435-248-2089
  • Fax: 801-207-5104

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number268496-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: