Provider Demographics
NPI:1417700626
Name:BAXTER, BRYANT DAKODA (MFT-I)
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:DAKODA
Last Name:BAXTER
Suffix:
Gender:M
Credentials:MFT-I
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 S DEEP CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:UT
Mailing Address - Zip Code:84780-3672
Mailing Address - Country:US
Mailing Address - Phone:801-599-0400
Mailing Address - Fax:
Practice Address - Street 1:254 S 1470 E STE 201
Practice Address - Street 2:
Practice Address - City:ST GEORGE
Practice Address - State:UT
Practice Address - Zip Code:84790-2762
Practice Address - Country:US
Practice Address - Phone:801-599-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist