Provider Demographics
NPI:1568065407
Name:GUILLORY, SAMANTHA FAY (CSW)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:FAY
Last Name:GUILLORY
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 N 400 E
Mailing Address - Street 2:
Mailing Address - City:NEPHI
Mailing Address - State:UT
Mailing Address - Zip Code:84648-1021
Mailing Address - Country:US
Mailing Address - Phone:435-287-5036
Mailing Address - Fax:
Practice Address - Street 1:11260 S RIVER HEIGHTS DRIVE
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095
Practice Address - Country:US
Practice Address - Phone:801-298-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT119348381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical