Healthcare Provider Details

I. General information

NPI: 1508176769
Provider Name (Legal Business Name): TIANA MAKAIWA PARK LOUIS LCADC, CPC-INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2010
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3970 S HOWICK ST UNIT B135
SALT LAKE CITY UT
84107-1491
US

IV. Provider business mailing address

3970 S HOWICK ST UNIT B135
SALT LAKE CITY UT
84107-1491
US

V. Phone/Fax

Practice location:
  • Phone: 702-271-9458
  • Fax:
Mailing address:
  • Phone: 702-271-9458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number127859346004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberCI0047
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number0022392
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: