Basic Information
| Provider Information | |||||||||
| NPI: | 1831554096 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POVEY | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 237 26TH ST | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844013105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016253700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 237 26TH ST | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844013105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8016253700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2015 | ||||||||
| LastUpdateDate: | 12/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 316315-3502 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 260022408 | 01 | UT | RAIL ROAD MEDICARE | OTHER | 876000308007 | 05 | UT | MEDICAID |