Provider Demographics
NPI:1124314711
Name:FEDO, MARY ELIZABETH
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELIZABETH
Last Name:FEDO
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:URBIZU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1270 MANDALAY RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4302
Mailing Address - Country:US
Mailing Address - Phone:801-953-0186
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S
Practice Address - Street 2:STE 301
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1700
Practice Address - Country:US
Practice Address - Phone:801-922-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT8019530186Medicaid