Healthcare Provider Details

I. General information

NPI: 1750893970
Provider Name (Legal Business Name): ANDREW REDD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2017
Last Update Date: 10/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

267 W CENTER ST
OREM UT
84057-4611
US

IV. Provider business mailing address

9160 S 300 W STE 3
SANDY UT
84070-2656
US

V. Phone/Fax

Practice location:
  • Phone: 801-572-4325
  • Fax:
Mailing address:
  • Phone: 801-572-4325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number6565423-6018
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: