Provider Demographics
NPI:1164537726
Name:GROW, KATHRYN STAMOS (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:STAMOS
Last Name:GROW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:
Other - Last Name:STAMOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3544 LINCOLN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-4034
Mailing Address - Country:US
Mailing Address - Phone:801-721-5550
Mailing Address - Fax:801-393-5025
Practice Address - Street 1:3544 LINCOLN AVE STE C
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84401-4034
Practice Address - Country:US
Practice Address - Phone:801-721-5550
Practice Address - Fax:801-393-5025
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2010-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3165563501101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT592631OtherVALUE OPTIONS
UT1C000060610Medicare PIN