Provider Demographics
NPI:1417775966
Name:MCDERMOTT, MATT
Entity type:Individual
Prefix:
First Name:MATT
Middle Name:
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2588 W 2365 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-1249
Mailing Address - Country:US
Mailing Address - Phone:801-975-7720
Mailing Address - Fax:801-975-7720
Practice Address - Street 1:2588 W 2365 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84119-1249
Practice Address - Country:US
Practice Address - Phone:801-975-7720
Practice Address - Fax:801-975-7720
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13204315-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical