Healthcare Provider Details

I. General information

NPI: 1336665264
Provider Name (Legal Business Name): KYLE S TAGGART CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 11/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2019 W 1900 S STE 140
SYRACUSE UT
84075-9643
US

IV. Provider business mailing address

2019 W 1900 S STE 140
SYRACUSE UT
84075-9643
US

V. Phone/Fax

Practice location:
  • Phone: 801-809-3398
  • Fax:
Mailing address:
  • Phone: 801-809-3398
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10832956-3502
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: