=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760223945
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARISSE HALES CSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2024
-----------------------------------------------------
Last Update Date | 06/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 512 W 750 S STE A
-----------------------------------------------------
City | WOODS CROSS
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84010-7221
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-935-8449
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2635 E STRINGHAM AVE APT C114
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84109-3919
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-528-2118
-----------------------------------------------------
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 | 134125703502
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041S0200X
-----------------------------------------------------
Taxonomy Name | School Social Worker
-----------------------------------------------------
License Number | 134125703502
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 134125703502
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------