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General NPI Number Information
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NPI Number | 1649860644
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Entity Type | Organization
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Legal Business Name | PSYCHOLOGY SPECIALISTS OF UTAH LLC
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Dates
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Enumeration Date | 01/22/2021
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Last Update Date | 01/22/2021
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Provider Practice Location Address
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Address Line | 87 N 600 E
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City | CENTERVILLE
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State | UT
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Zip | 84014-2020
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Country | US
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Telephone | 405-315-5756
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Fax |
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Provider Business Mailing Address
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Address Line | 87 N 600 E
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City | CENTERVILLE
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State | UT
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Zip | 84014-2020
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Country | US
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Telephone | 405-315-5756
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CARL ROBERT EDGINGTON
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Credential | PH.D.
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Telephone | 405-315-5756
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number |
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License Number State |
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