Healthcare Provider Details

I. General information

NPI: 1124684709
Provider Name (Legal Business Name): MEAGAN LAVELLE BROOKS CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 S 400 W STE 102
OREM UT
84058-5359
US

IV. Provider business mailing address

36 S 400 W STE 102
OREM UT
84058-5359
US

V. Phone/Fax

Practice location:
  • Phone: 801-251-6884
  • Fax:
Mailing address:
  • Phone: 801-251-6884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11256803-3502
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier11256803-3502
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerDOPL LICENSING NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: