Basic Information
| Provider Information | |||||||||
| NPI: | 1164625786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHILD | ||||||||
| FirstName: | CATHIE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | L.P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5436 W 4000 S | ||||||||
| Address2: | |||||||||
| City: | HOOPER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 843159611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017313963 | ||||||||
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| Practice Location | |||||||||
| Address1: | 237 26TH ST | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844013105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016253700 | ||||||||
| FaxNumber: | 8017786878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 336167-6004 | UT | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 876000308007 | 05 | UT | MEDICAID |