MEDICARE: PRESTON ROBERT DAHLGREN MFT

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	106H00000X	Marriage & Family Therapist	7240205-3902	UT

General Provider Information

NPI Number	:	1275123077
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRESTON ROBERT DAHLGREN MFT

Provider Business Mailing Address
First Line	:	10808 S RIVER FRONT PKWY STE 361
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-6300
Country	:	US
Telephone Number	:	801-900-6047
Fax Number	:

Provider Business Practice Location Address
First Line	:	10808 S RIVER FRONT PKWY STE 361
Second Line	:
City	:	SOUTH JORDAN
State	:	UT
Zip	:	84095-6300
Country	:	US
Telephone Number	:	801-900-6047
Fax Number	:

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

Provider Enumeration Date	:	01/25/2021
Last Update Date	:	01/25/2021

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