Provider Demographics
NPI:1487246377
Name:GHADIKOLAI, ATUSA
Entity type:Individual
Prefix:
First Name:ATUSA
Middle Name:
Last Name:GHADIKOLAI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1459 N MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6092
Mailing Address - Country:US
Mailing Address - Phone:801-298-2000
Mailing Address - Fax:801-951-1490
Practice Address - Street 1:11260 S RIVER HEIGHTS DRIVE
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-8409
Practice Address - Country:US
Practice Address - Phone:801-298-2000
Practice Address - Fax:801-951-1490
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12022709-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical