1598743502 NPI number — RANDAL THERON DOW JR. LCSW

Table of content: RANDAL THERON DOW JR. LCSW (NPI 1598743502)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598743502 NPI number — RANDAL THERON DOW JR. LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOW
Provider First Name:
RANDAL
Provider Middle Name:
THERON
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
LCSW
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DOW
Provider Other First Name:
RANDAL
Provider Other Middle Name:
T
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LCSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1598743502
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3809 W 6200 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEARNS
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84118-3725
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-963-4215
Provider Business Mailing Address Fax Number:
801-963-4299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3809 W 6200 S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEARNS
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84118-3725
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-963-4215
Provider Business Practice Location Address Fax Number:
801-963-4299
Provider Enumeration Date:
01/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  881346053501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13460535000001 . This is a "BLUE CROSS" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 107001374101 . This is a "INTERMOUNTAIN HEALTH CARE" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".
  • Identifier: 261880 . This is a "DESERET MUTUAL" identifier , issued by the state of ( UT ) . This identifiers is of the category "OTHER".




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