MEDICARE: KRISTEN STODDARD ACMHC

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	87378866009	UT

General Provider Information

NPI Number	:	1588080675
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN STODDARD ACMHC

Provider Business Mailing Address
First Line	:	574 E FIREICE ROSE LN
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84070-2801
Country	:	US
Telephone Number	:	570-470-7936
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 E 700 S
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84111-3806
Country	:	US
Telephone Number	:	801-364-8080
Fax Number	:

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

Provider Enumeration Date	:	03/12/2014
Last Update Date	:	03/12/2014

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Directions to “ KRISTEN STODDARD ACMHC” Practice Location

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