Provider Demographics
NPI:1629885058
Name:PACKER, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:PACKER
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 1:9300 S REDWOOD RD APT 2110
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-6665
Mailing Address - Country:US
Mailing Address - Phone:385-867-8215
Mailing Address - Fax:
Practice Address - Street 1:1053 W 1020 S
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-5656
Practice Address - Country:US
Practice Address - Phone:801-810-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14114005-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health