Provider Demographics
NPI:1043556038
Name:FAWCETT, DAVID (PHD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:FAWCETT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2790 E 3000 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109-2037
Mailing Address - Country:US
Mailing Address - Phone:801-484-0112
Mailing Address - Fax:
Practice Address - Street 1:5667 S REDWOOD RD
Practice Address - Street 2:SUITE #6B
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123-5433
Practice Address - Country:US
Practice Address - Phone:801-979-1351
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7693790-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist