Provider Demographics
NPI:1255084067
Name:MCKIBBIN, ELAINE
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:MCKIBBIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:ELAINE
Other - Middle Name:LAINE
Other - Last Name:MCKIBBIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:380 S 400 E APT 427
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2933
Mailing Address - Country:US
Mailing Address - Phone:435-901-3921
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S STE 301
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1727
Practice Address - Country:US
Practice Address - Phone:801-428-4257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)