Basic Information
| Provider Information | |||||||||
| NPI: | 1215196647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | JOAN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5965 S 900 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841211720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012637100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 S 1000 W | ||||||||
| Address2: | |||||||||
| City: | TOOELE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840744010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358433520 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2008 | ||||||||
| LastUpdateDate: | 07/27/2012 | ||||||||
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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 | 1041C0700X | 54668946501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.