MEDICARE: KATIE POULSEN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1013507466
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATIE POULSEN

Provider Business Mailing Address
First Line	:	152 N 400 W
Second Line	:
City	:	EPHRAIM
State	:	UT
Zip	:	84627-5549
Country	:	US
Telephone Number	:	435-283-8400
Fax Number	:	435-283-8401

Provider Business Practice Location Address
First Line	:	51 N CENTER ST
Second Line	:
City	:	DELTA
State	:	UT
Zip	:	84624-8430
Country	:	US
Telephone Number	:	435-864-3073
Fax Number	:	435-864-3610

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2021
Last Update Date	:	01/20/2021

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Directions to “ KATIE POULSEN ” Practice Location

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