Healthcare Provider Details

I. General information

NPI: 1083966519
Provider Name (Legal Business Name): KRISTEN DRASKOVIC LCSW, RN, RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 07/26/2022
Certification Date: 05/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4590 HARRISON BLVD STE 200B
OGDEN UT
84403-3350
US

IV. Provider business mailing address

1910 BUCHANAN AVE
OGDEN UT
84401-0913
US

V. Phone/Fax

Practice location:
  • Phone: 701-866-2612
  • Fax:
Mailing address:
  • Phone: 701-866-2612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11601167-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number11601167-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: