Provider Demographics
NPI:1033551064
Name:FREITAG, MALINDA JO
Entity Type:Individual
Prefix:
First Name:MALINDA
Middle Name:JO
Last Name:FREITAG
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 1:5242 S 4820 W
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-6422
Mailing Address - Country:US
Mailing Address - Phone:801-747-9257
Mailing Address - Fax:
Practice Address - Street 1:5242 S 4820 W
Practice Address - Street 2:
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-6422
Practice Address - Country:US
Practice Address - Phone:801-747-9257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8650416-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health