Provider Demographics
NPI:1992775415
Name:KWAN, FAN LEE (MSW)
Entity type:Individual
Prefix:MRS
First Name:FAN
Middle Name:LEE
Last Name:KWAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6294 TERRACE RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84128-5604
Mailing Address - Country:US
Mailing Address - Phone:801-964-5185
Mailing Address - Fax:
Practice Address - Street 1:7434 S STATE ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2014
Practice Address - Country:US
Practice Address - Phone:801-566-4423
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT369290-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107018309101OtherU006
UTQ10178OtherICAR
UT942938348KW1OtherU003
UT802652OtherU002
UT942938348KW1OtherU003
UT802652OtherU002
UTU000073802Medicare PIN
UT000062225Medicare PIN