Healthcare Provider Details

I. General information

NPI: 1669399655
Provider Name (Legal Business Name): GRACE BERRY MAYCOCK C.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W BAMBERGER DR
RIVERTON UT
84065-7537
US

IV. Provider business mailing address

5824 S HOLSTEIN WAY
MURRAY UT
84107-6542
US

V. Phone/Fax

Practice location:
  • Phone: 385-309-2229
  • Fax:
Mailing address:
  • Phone: 385-309-2229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14291702-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: