Healthcare Provider Details

I. General information

NPI: 1689932154
Provider Name (Legal Business Name): MRS. CAROL SUE KOFFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CAROL SUE MESSERLY LCSW

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 05/02/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 PARK AVE STE 2065
PARK CITY UT
84060-5160
US

IV. Provider business mailing address

1700 PARK AVE STE 2065
PARK CITY UT
84060-5160
US

V. Phone/Fax

Practice location:
  • Phone: 435-659-4508
  • Fax:
Mailing address:
  • Phone: 435-659-4508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number65418483501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: