Healthcare Provider Details

I. General information

NPI: 1750940409
Provider Name (Legal Business Name): CRYSTAL DRAPER-TERVORT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CRYSTAL GATRELL

II. Dates (important events)

Enumeration Date: 06/06/2019
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1858 W 5150 S
ROY UT
84067-3000
US

IV. Provider business mailing address

6013 S REDWOOD RD
TAYLORSVILLE UT
84123-5220
US

V. Phone/Fax

Practice location:
  • Phone: 801-255-5131
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: