Provider Demographics
NPI:1699076851
Name:COBURN, ANN TALLEY (LSAC)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:TALLEY
Last Name:COBURN
Suffix:
Gender:F
Credentials:LSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4187 S 3425 W
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-5079
Mailing Address - Country:US
Mailing Address - Phone:801-755-1580
Mailing Address - Fax:801-233-8682
Practice Address - Street 1:7601 SOUTH REDWOOD RD.
Practice Address - Street 2:BUILDING E
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84084
Practice Address - Country:US
Practice Address - Phone:801-233-8670
Practice Address - Fax:801-233-8682
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2010-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT68526866006101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)