Provider Demographics
NPI:1003405192
Name:FEGTER, OLIVIA DAWN
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:DAWN
Last Name:FEGTER
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 1:475 W 1720 N APT 113
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-6428
Mailing Address - Country:US
Mailing Address - Phone:630-731-4835
Mailing Address - Fax:
Practice Address - Street 1:1140 W 1130 S SUITE B
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058
Practice Address - Country:US
Practice Address - Phone:630-731-4835
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-13
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician