Provider Demographics
NPI:1396152153
Name:KOMATSU, MEGAN (LCSW)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:
Last Name:KOMATSU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:KOMATSU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:5004 W SARASOTA LN
Mailing Address - Street 2:
Mailing Address - City:HERRIMAN
Mailing Address - State:UT
Mailing Address - Zip Code:84096-1479
Mailing Address - Country:US
Mailing Address - Phone:801-455-0150
Mailing Address - Fax:
Practice Address - Street 1:10815 S 700 E # 300
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4702
Practice Address - Country:US
Practice Address - Phone:801-867-3472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT88429061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical