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NPI Code Detail

MEDICARE: RANDAL THERON DOW JR. LCSW

MEDICARE: RANDAL THERON DOW JR. LCSW
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
11041C0700XClinical Social Worker881346053501UT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
113460535000001OTHERUTBLUE CROSS
2107001374101OTHERUTINTERMOUNTAIN HEALTH CARE
3261880OTHERUTDESERET MUTUAL

General Provider Information

NPI Number : 1598743502
Entity Type Code : Individual
Provider Name (Legal Business Name) : RANDAL THERON DOW JR. LCSW
Provider Business Mailing Address
First Line : 3809 W 6200 S
Second Line :
City : KEARNS
State : UT
Zip : 84118-3725
Country : US
Telephone Number : 801-963-4215
Fax Number : 801-963-4299
Provider Business Practice Location Address
First Line : 3809 W 6200 S
Second Line :
City : KEARNS
State : UT
Zip : 84118-3725
Country : US
Telephone Number : 801-963-4215
Fax Number : 801-963-4299
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/09/2006
Last Update Date : 07/08/2007

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