Basic Information
| Provider Information | |||||||||
| NPI: | 1285843938 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BART | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1240 E 100 S | ||||||||
| Address2: | STE 121 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847903079 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356345600 | ||||||||
| FaxNumber: | 4359868700 | ||||||||
| Practice Location | |||||||||
| Address1: | 474 W 200 N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847704505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356345600 | ||||||||
| FaxNumber: | 4359868700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 04/19/2017 | ||||||||
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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 | 104100000X | 6312436-3502 | UT | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 63124363501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6312436-3502 | 01 | UT | STATE LICENSE | OTHER |