=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588131171
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATRINA RACHEL VANTASSELL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2018
-----------------------------------------------------
Last Update Date | 09/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1950 CIRCLE OF HOPE DR
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84112-5500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-646-9697
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 463 E BRIDLEWOOD DR
-----------------------------------------------------
City | MILLCREEK
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84107-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-668-2514
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6802090222
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041S0200X
-----------------------------------------------------
Taxonomy Name | School Social Worker
-----------------------------------------------------
License Number | 11881338-3502
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 118813383504
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------