Healthcare Provider Details

I. General information

NPI: 1447088497
Provider Name (Legal Business Name): MARC ANTHONY AVALOS-GOMEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7625 S 3200 W STE 2
WEST JORDAN UT
84084-2887
US

IV. Provider business mailing address

3306 W 3500 S APT 1B
WEST VALLEY CITY UT
84119-2684
US

V. Phone/Fax

Practice location:
  • Phone: 801-915-0359
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14224526-3502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: