Provider Demographics
NPI:1396118212
Name:DAWES, MICHAEL (MFT)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DAWES
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 W PRICE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-4345
Mailing Address - Country:US
Mailing Address - Phone:385-468-4500
Mailing Address - Fax:385-468-4461
Practice Address - Street 1:177 W PRICE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-4345
Practice Address - Country:US
Practice Address - Phone:385-468-4500
Practice Address - Fax:385-468-4461
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106H00000X106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTHT 002258-001OtherMEDICAID