Basic Information
| Provider Information | |||||||||
| NPI: | 1477561587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LISTER | ||||||||
| FirstName: | ROGER | ||||||||
| MiddleName: | KAY | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LISTER | ||||||||
| OtherFirstName: | KAY | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 474 W 200 N | ||||||||
| Address2: | #300 | ||||||||
| City: | ST GEORGE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847704505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4356345621 | ||||||||
| FaxNumber: | 4359868700 | ||||||||
| Practice Location | |||||||||
| Address1: | 245 E 680 S | ||||||||
| Address2: | |||||||||
| City: | CEDAR CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 847203593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4358677654 | ||||||||
| FaxNumber: | 4358677699 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 132391-3501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.