Provider Demographics
NPI:1285392340
Name:THOMAS, MAKENNA ANNE
Entity type:Individual
Prefix:
First Name:MAKENNA
Middle Name:ANNE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9894 N YORKSHIRE CT
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:UT
Mailing Address - Zip Code:84003-3477
Mailing Address - Country:US
Mailing Address - Phone:801-857-5450
Mailing Address - Fax:
Practice Address - Street 1:714 S STATE ST
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-6366
Practice Address - Country:US
Practice Address - Phone:801-426-6565
Practice Address - Fax:801-426-6464
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11610721-6014101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)