Provider Demographics
NPI:1043091960
Name:AGING CLINIC OF SOUTHERN UTAH PLLC
Entity Type:Organization
Organization Name:AGING CLINIC OF SOUTHERN UTAH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:KIRSTEN
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:GRAHAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:435-277-0285
Mailing Address - Street 1:94 S 300 E
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-3318
Mailing Address - Country:US
Mailing Address - Phone:435-277-0285
Mailing Address - Fax:
Practice Address - Street 1:94 S 300 E
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-3318
Practice Address - Country:US
Practice Address - Phone:435-277-0285
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-06
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty