Basic Information
| Provider Information | |||||||||
| NPI: | 1336154632 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDGMON | ||||||||
| FirstName: | KREG | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840250689 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2250 ROBINS DR | ||||||||
| Address2: | |||||||||
| City: | LAYTON | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840411140 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017737060 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 370940-3902 | UT | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.