=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053139758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA FREW MCCORMACK INTERN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2024
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5300 S 500 E STE 6
-----------------------------------------------------
City | OGDEN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84405-6955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-392-0942
-----------------------------------------------------
Fax | 801-392-0943
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2980 W 4650 S
-----------------------------------------------------
City | ROY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84067-8956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 385-444-5004
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------