Provider Demographics
NPI:1578780441
Name:VAKA'UTA, EDWARD DOUGLAS (LCSW)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:DOUGLAS
Last Name:VAKA'UTA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9067 S 1300 W STE 204
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5582
Mailing Address - Country:US
Mailing Address - Phone:801-253-4877
Mailing Address - Fax:801-748-2192
Practice Address - Street 1:9067 S 1300 W
Practice Address - Street 2:SUITE 204
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5581
Practice Address - Country:US
Practice Address - Phone:801-253-4877
Practice Address - Fax:801-748-2192
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5138304-3501101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical