Healthcare Provider Details

I. General information

NPI: 1669766317
Provider Name (Legal Business Name): KIP T RISHTON CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2011
Last Update Date: 05/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 COMMERCE DR STE 190
MURRAY UT
84107-7926
US

IV. Provider business mailing address

931 GOLDEN PHEASANT DR
DRAPER UT
84020-8462
US

V. Phone/Fax

Practice location:
  • Phone: 801-577-4065
  • Fax:
Mailing address:
  • Phone: 801-577-4065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5462356-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: