Provider Demographics
NPI:1629419593
Name:LEAVITT, MAGGI (LMFT)
Entity Type:Individual
Prefix:
First Name:MAGGI
Middle Name:
Last Name:LEAVITT
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:MAGGI
Other - Middle Name:
Other - Last Name:QUACKENBUSH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:43 E 640 S
Mailing Address - Street 2:
Mailing Address - City:EPHRAIM
Mailing Address - State:UT
Mailing Address - Zip Code:84627-3029
Mailing Address - Country:US
Mailing Address - Phone:801-427-5436
Mailing Address - Fax:
Practice Address - Street 1:43 E 640 S
Practice Address - Street 2:
Practice Address - City:EPHRAIM
Practice Address - State:UT
Practice Address - Zip Code:84627-3029
Practice Address - Country:US
Practice Address - Phone:801-427-5436
Practice Address - Fax:801-427-5436
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5040273-3902101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health