Healthcare Provider Details

I. General information

NPI: 1558071027
Provider Name (Legal Business Name): TAVA CLINICAL SERVICES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2022
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E 7TH AVE
SALT LAKE CITY UT
84103-2518
US

IV. Provider business mailing address

PO BOX 581406
SALT LAKE CITY UT
84158-1406
US

V. Phone/Fax

Practice location:
  • Phone: 385-406-2867
  • Fax: 801-992-8269
Mailing address:
  • Phone: 385-406-2867
  • Fax: 801-992-8269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DALLEN ALLRED
Title or Position: CEO
Credential:
Phone: 801-319-6471