Basic Information
| Provider Information | |||||||||
| NPI: | 1588131171 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANTASSELL | ||||||||
| FirstName: | KATRINA | ||||||||
| MiddleName: | RACHEL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1375 S 900 E APT 7 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841052339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016682514 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9361 S 300 E | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840702902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018265000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6802090222 | MI | N | Behavioral Health & Social Service Providers | Social Worker | 1041S0200X | 11881338-3502 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | School |
No ID Information.