Basic Information
| Provider Information | |||||||||
| NPI: | 1275812166 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GREEN | ||||||||
| FirstName: | RACHAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6013 S REDWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841235220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012555131 | ||||||||
| FaxNumber: | 8012555131 | ||||||||
| Practice Location | |||||||||
| Address1: | 6013 S REDWOOD RD | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841235220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012555131 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2011 | ||||||||
| LastUpdateDate: | 01/17/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 8368793-2506 | UT | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst | 1041C0700X | 8368793-3502 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 260022408 | 01 | UT | RAILROAD MEDICARE | OTHER | 876000308007 | 05 | UT | MEDICAID |