Basic Information
Provider Information | |||||||||
NPI: | 1568082360 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PARKER | ||||||||
FirstName: | EMILY | ||||||||
MiddleName: | MOULTON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PHD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOULTON | ||||||||
OtherFirstName: | EMILY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PHD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3521 S 1200 E FRNT | ||||||||
Address2: |   | ||||||||
City: | MILLCREEK | ||||||||
State: | UT | ||||||||
PostalCode: | 841064489 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2159137403 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 81 N MARIO CAPECCHI DR | ||||||||
Address2: |   | ||||||||
City: | SALT LAKE CITY | ||||||||
State: | UT | ||||||||
PostalCode: | 841131125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8015812205 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2020 | ||||||||
LastUpdateDate: | 11/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 11488528-2501 | UT | Y |   | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.