Basic Information
| Provider Information | |||||||||
| NPI: | 1124370440 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHRISTENSEN | ||||||||
| FirstName: | BRAD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 351 S GOSHEN ST | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CTY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841041217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016430004 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5965 S 900 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841211720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012637100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2012 | ||||||||
| LastUpdateDate: | 05/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 1041C0700X | 9169380-3501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.