Healthcare Provider Details

I. General information

NPI: 1649069725
Provider Name (Legal Business Name): JUSTIN PHILLIP HUDAK PHD, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2025
Last Update Date: 05/05/2025
Certification Date: 05/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5882 S 900 E STE 303
MURRAY UT
84121-1693
US

IV. Provider business mailing address

2002 S DOUGLAS ST UNIT 1
SALT LAKE CITY UT
84105-3624
US

V. Phone/Fax

Practice location:
  • Phone: 385-414-7704
  • Fax:
Mailing address:
  • Phone: 385-414-7704
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13105346-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: