Healthcare Provider Details

I. General information

NPI: 1083089403
Provider Name (Legal Business Name): DANIELLE DEARDEN MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2015
Last Update Date: 06/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1435 VILLAGE DR DEPT 2805
OGDEN UT
84408-2805
US

IV. Provider business mailing address

129 N COMMERCIAL ST
MORGAN UT
84050-9570
US

V. Phone/Fax

Practice location:
  • Phone: 801-626-7656
  • Fax:
Mailing address:
  • Phone: 801-845-1403
  • Fax: 801-845-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number10384137-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: