Provider Demographics
NPI:1639225956
Name:INNES, BRENT W
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:W
Last Name:INNES
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:BRENT
Other - Middle Name:W
Other - Last Name:INNES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2082 E 6075 S
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-5240
Mailing Address - Country:US
Mailing Address - Phone:801-479-4231
Mailing Address - Fax:
Practice Address - Street 1:3518 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1034
Practice Address - Country:US
Practice Address - Phone:801-399-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT107425-3501101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107425-3501OtherLCSW