=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780400994
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AIRYN REYES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2024
-----------------------------------------------------
Last Update Date | 12/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 375 N MAIN ST STE 102
-----------------------------------------------------
City | KAYSVILLE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84037-1272
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-989-3488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1111 E BRICKYARD RD APT 215
-----------------------------------------------------
City | SALT LAKE CITY
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84106-2690
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-336-6599
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 13054342-3501
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------