Provider Demographics
NPI:1073877767
Name:LEAAETOA, KRYSTAL MITCHELL
Entity Type:Individual
Prefix:
First Name:KRYSTAL
Middle Name:MITCHELL
Last Name:LEAAETOA
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 1:1672 W 700 S
Mailing Address - Street 2:SUITE D
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-4963
Mailing Address - Country:US
Mailing Address - Phone:801-489-9721
Mailing Address - Fax:
Practice Address - Street 1:1672 W 700 S
Practice Address - Street 2:SUITE D
Practice Address - City:SPRINGVILLE
Practice Address - State:UT
Practice Address - Zip Code:84663-4963
Practice Address - Country:US
Practice Address - Phone:801-489-9721
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2012-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7114746-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker