Provider Demographics
NPI:1467064105
Name:HEREDIA, DENISSE
Entity Type:Individual
Prefix:
First Name:DENISSE
Middle Name:
Last Name:HEREDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DENISSE
Other - Middle Name:
Other - Last Name:BONILLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:738 S 170 W
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-4747
Mailing Address - Country:US
Mailing Address - Phone:424-731-6006
Mailing Address - Fax:
Practice Address - Street 1:879 S OREM BLVD STE 1
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5030
Practice Address - Country:US
Practice Address - Phone:801-802-8608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT223222332OtherSTATE ID