Healthcare Provider Details

I. General information

NPI: 1386155380
Provider Name (Legal Business Name): CARLY LOUISE ROST MS, LCGC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5131 S COTTONWOOD ST BLDG 3
MURRAY UT
84107-5701
US

IV. Provider business mailing address

5131 S COTTONWOOD STREET BUILDING 3, LEVEL 3
MURRAY UT
84107
US

V. Phone/Fax

Practice location:
  • Phone: 801-507-4048
  • Fax: 801-507-3998
Mailing address:
  • Phone: 801-507-4048
  • Fax: 801-507-3998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number10466385-3602
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: