Basic Information
| Provider Information | |||||||||
| NPI: | 1780858662 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TAVERNE | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | F | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FULLER | ||||||||
| OtherFirstName: | ANNE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 5242 SO. 4820 W. | ||||||||
| Address2: | THE CHILDREN'S CENTER | ||||||||
| City: | SLC | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841186422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019664251 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5242 SO. 4820 W. | ||||||||
| Address2: | THE CHILDREN'S CENTER | ||||||||
| City: | SLC | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841186422 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019664251 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2008 | ||||||||
| LastUpdateDate: | 09/17/2009 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 363423-2501 | UT | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 1780858662 | 01 | UT | NPI | OTHER |