Provider Demographics
NPI:1104317627
Name:CHARGO, BENNETT JOSEPH
Entity type:Individual
Prefix:
First Name:BENNETT
Middle Name:JOSEPH
Last Name:CHARGO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1877 S 200 E APT 11
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2158
Mailing Address - Country:US
Mailing Address - Phone:952-239-2754
Mailing Address - Fax:
Practice Address - Street 1:1832 N 1120 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-1179
Practice Address - Country:US
Practice Address - Phone:801-495-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10834959-4101231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist