Provider Demographics
NPI:1538538525
Name:MARY BETH WHITTAKER LCSW
Entity type:Organization
Organization Name:MARY BETH WHITTAKER LCSW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:BETH
Authorized Official - Last Name:WHITTAKER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-272-3533
Mailing Address - Street 1:2290 E 4500 S
Mailing Address - Street 2:SUITE 210
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4492
Mailing Address - Country:US
Mailing Address - Phone:801-272-3533
Mailing Address - Fax:801-272-3636
Practice Address - Street 1:2290 E 4500 S
Practice Address - Street 2:SUITE 210
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-4492
Practice Address - Country:US
Practice Address - Phone:801-272-3533
Practice Address - Fax:801-272-3636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-19
Last Update Date:2015-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT130283-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000060603Medicare UPIN