Healthcare Provider Details

I. General information

NPI: 1720564362
Provider Name (Legal Business Name): SKIP A HENRIE LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2018
Last Update Date: 07/17/2018
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

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

V. Phone/Fax

Practice location:
  • Phone: 801-261-3500
  • Fax: 801-261-2111
Mailing address:
  • Phone: 801-261-3500
  • Fax: 801-261-2111

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6752601-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: