=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285100784
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TRACEY M WILLIAMS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/23/2018
-----------------------------------------------------
Last Update Date | 10/23/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13200 S 1601 E
-----------------------------------------------------
City | DRAPER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 385-255-9117
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13200 S 1601 E
-----------------------------------------------------
City | DRAPER
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 385-255-9117
-----------------------------------------------------
Fax | 801-432-8716
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Psychologist
-----------------------------------------------------
License Number | 4848969-6006
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------