Healthcare Provider Details

I. General information

NPI: 1720066442
Provider Name (Legal Business Name): DEBRA MARIE QUACKENBUSH PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEBBIE QUACKENBUSH

II. Dates (important events)

Enumeration Date: 01/03/2006
Last Update Date: 08/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1399 S 700 E
SALT LAKE CITY UT
84105-2160
US

IV. Provider business mailing address

2259 WELLINGTON ST
SALT LAKE CITY UT
84106-4118
US

V. Phone/Fax

Practice location:
  • Phone: 801-832-1050
  • Fax:
Mailing address:
  • Phone: 801-322-2876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number334840-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: