Healthcare Provider Details

I. General information

NPI: 1881096097
Provider Name (Legal Business Name): NADA BREANNA PLOOSTER CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

135 W CENTER ST
PLEASANT GROVE UT
84062-2207
US

IV. Provider business mailing address

521 W 810 S
LEHI UT
84043-3955
US

V. Phone/Fax

Practice location:
  • Phone: 801-785-1169
  • Fax:
Mailing address:
  • Phone: 435-503-4743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number8617338-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: