Healthcare Provider Details

I. General information

NPI: 1659984847
Provider Name (Legal Business Name): MADELEINE SUSANNA HOMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2020
Last Update Date: 05/27/2022
Certification Date: 05/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9361 S 300 E
SANDY UT
84070-2902
US

IV. Provider business mailing address

7750 S 300 E
MIDVALE UT
84047-2725
US

V. Phone/Fax

Practice location:
  • Phone: 801-826-5000
  • Fax:
Mailing address:
  • Phone: 801-696-7436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: