Basic Information
| Provider Information | |||||||||
| NPI: | 1255352878 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAKER | ||||||||
| FirstName: | DENNIS | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 27128 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841270128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013875620 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5030 HARRISON BLVD | ||||||||
| Address2: | |||||||||
| City: | OGDEN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844034311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013875620 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 12/04/2012 | ||||||||
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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 | 103G00000X | 49444202501 | UT | Y | Behavioral Health & Social Service Providers | Clinical Neuropsychologist | 103T00000X | 49444202501 | UT | N | Behavioral Health & Social Service Providers | Psychologist |
No ID Information.