Healthcare Provider Details

I. General information

NPI: 1811885361
Provider Name (Legal Business Name): CODY RAY SMITH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2025
Last Update Date: 06/25/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1429 S 550 E STE 240
OREM UT
84097-7795
US

IV. Provider business mailing address

1429 S 550 E STE 240
OREM UT
84097-7795
US

V. Phone/Fax

Practice location:
  • Phone: 801-382-9455
  • Fax:
Mailing address:
  • Phone: 801-382-9455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: