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9844 S 1300 E Ste 250 Sandy UT 84094-4691 | |
| (801) 810-5037 | |
| (801) 609-3649 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 9844 S 1300 E Ste 250, Sandy, Utah |
| Authorized Official Name and Position | Jason Robert Wagner (OWNER) |
| Authorized Official Contact | 8012432928 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
9844 S 1300 E Ste 250 Sandy UT 84094-4691 Ph: (801) 810-5037 | 9844 S 1300 E Ste 250 Sandy UT 84094-4691 Ph: (801) 810-5037 |
| NPI Number | 1811526122 |
|---|---|
| Provider Enumeration Date | 04/07/2020 |
| Last Update Date | 12/10/2024 |
| Certification Date | 12/10/2024 |
| Medicare PECOS PAC ID | 8628414786 |
|---|---|
| Medicare Enrollment ID | O20240311004019 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1811526122 | NPI | - | NPPES |
| Provider Name | Joshua D Henricksen |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1457018269 PECOS PAC ID: 5395192546 Enrollment ID: I20240826004140 |
| Provider Name | Courtney M Davies |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1982205936 PECOS PAC ID: 0840723987 Enrollment ID: I20241029001558 |
| Provider Name | Jason Wagner |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1053700765 PECOS PAC ID: 3870030018 Enrollment ID: I20241029003155 |
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