Provider Demographics
NPI:1649225533
Name:HENDREN, ANGIE SUZANNE
Entity Type:Individual
Prefix:
First Name:ANGIE
Middle Name:SUZANNE
Last Name:HENDREN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4973 BRIDLE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-3667
Mailing Address - Country:US
Mailing Address - Phone:801-455-8958
Mailing Address - Fax:
Practice Address - Street 1:731 E 8600 S
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-6312
Practice Address - Country:US
Practice Address - Phone:801-561-9987
Practice Address - Fax:801-561-9987
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2008-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT33024-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT33020460001001OtherREGENCE PROVIDER ID
UT870476172-008OtherVALLEY MENTAL HEALTH
UT89204OtherPEHP PROVIDER ID