Provider Demographics
NPI:1508588237
Name:PAULK, EJA
Entity Type:Individual
Prefix:MRS
First Name:EJA
Middle Name:
Last Name:PAULK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EJA
Other - Middle Name:
Other - Last Name:BRAITHWAITE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1955 N 550 W APT 401
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1440
Mailing Address - Country:US
Mailing Address - Phone:801-916-4718
Mailing Address - Fax:
Practice Address - Street 1:935 S OREM BLVD
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-5011
Practice Address - Country:US
Practice Address - Phone:801-062-3677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical