Healthcare Provider Details

I. General information

NPI: 1578780441
Provider Name (Legal Business Name): EDWARD DOUGLAS VAKA'UTA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9067 S 1300 W SUITE 204
WEST JORDAN UT
84088-5581
US

IV. Provider business mailing address

9067 S 1300 W STE 204
WEST JORDAN UT
84088-5582
US

V. Phone/Fax

Practice location:
  • Phone: 801-253-4877
  • Fax: 801-748-2192
Mailing address:
  • Phone: 801-253-4877
  • Fax: 801-748-2192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5138304-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5138304-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: