Provider Demographics
NPI:1386142396
Name:SOUTH DAVIS PSYCHOLOGICAL SERVICES
Entity type:Organization
Organization Name:SOUTH DAVIS PSYCHOLOGICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:AHERN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-934-3373
Mailing Address - Street 1:520 N MARKET PLACE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-4904
Mailing Address - Country:US
Mailing Address - Phone:801-934-3373
Mailing Address - Fax:
Practice Address - Street 1:520 N MARKET PLACE DR STE 200
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014-4904
Practice Address - Country:US
Practice Address - Phone:801-934-3373
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-24
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1437400447Medicaid