Provider Demographics
NPI:1427285444
Name:EDGINGTON, CARL ROBERT (PHD)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:ROBERT
Last Name:EDGINGTON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:CHUCK
Other - Middle Name:
Other - Last Name:EDGINGTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:87 N 600 E
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-2020
Mailing Address - Country:US
Mailing Address - Phone:405-315-5756
Mailing Address - Fax:
Practice Address - Street 1:515 S 700 E STE 2A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2855
Practice Address - Country:US
Practice Address - Phone:801-935-4171
Practice Address - Fax:801-935-4946
Is Sole Proprietor?:No
Enumeration Date:2009-06-17
Last Update Date:2021-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT354718-2501103TC0700X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical