Provider Demographics
NPI:1073268470
Name:DEREK CRAGUN, LCSW PLLC
Entity Type:Organization
Organization Name:DEREK CRAGUN, LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEREK
Authorized Official - Middle Name:
Authorized Official - Last Name:CRAGUN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-875-7534
Mailing Address - Street 1:169 E KELSEY AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-4508
Mailing Address - Country:US
Mailing Address - Phone:801-875-7534
Mailing Address - Fax:
Practice Address - Street 1:169 E KELSEY AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-4508
Practice Address - Country:US
Practice Address - Phone:801-875-7534
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-15
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty