Healthcare Provider Details

I. General information

NPI: 1407783665
Provider Name (Legal Business Name): DEDRIC DEAN DAVIDSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6469 W 7910 S
WEST JORDAN UT
84081-5885
US

IV. Provider business mailing address

6469 W 7910 S
WEST JORDAN UT
84081-5885
US

V. Phone/Fax

Practice location:
  • Phone: 435-660-1921
  • Fax:
Mailing address:
  • Phone: 435-660-1921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10858154-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: