=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639919996
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTY DAVIS SSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2024
-----------------------------------------------------
Last Update Date | 05/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12447 S CROSSING DR STE 13
-----------------------------------------------------
City | RIVERTON
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84096-7020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-984-0184
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11091 N 5550 W
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84003-9577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-494-9431
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number | 6771454-3503
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6771454-3503
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------