Provider Demographics
NPI:1578870747
Name:MCDOUGAL, KRISTINA RAE (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:RAE
Last Name:MCDOUGAL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:MCDOUGL
Other - Last Name:HUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3055 W 4450 S
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-9559
Mailing Address - Country:US
Mailing Address - Phone:801-631-2380
Mailing Address - Fax:
Practice Address - Street 1:1140 36TH ST
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-2050
Practice Address - Country:US
Practice Address - Phone:801-631-2380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-08
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7711976-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker