Basic Information
Provider Information | |||||||||
NPI: | 1396970786 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CHYNOWETH PRENTICE | ||||||||
FirstName: | MOLLY | ||||||||
MiddleName: | KATHLEEN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LCSW | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PRENTICE | ||||||||
OtherFirstName: | MOLLY | ||||||||
OtherMiddleName: | KATHLEEN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | LCSW | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3845 BURNINGHAM DR | ||||||||
Address2: |   | ||||||||
City: | WEST VALLEY CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841194767 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8016430136 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1208 E 3300 S | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841062522 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8014831600 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/28/2009 | ||||||||
LastUpdateDate: | 05/28/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 372156-3501 | UT | Y |   | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.