Provider Demographics
NPI:1659984847
Name:HOMER, MADELEINE SUSANNA
Entity Type:Individual
Prefix:
First Name:MADELEINE
Middle Name:SUSANNA
Last Name:HOMER
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 1:7750 S 300 E
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2725
Mailing Address - Country:US
Mailing Address - Phone:801-696-7436
Mailing Address - Fax:
Practice Address - Street 1:9361 S 300 E
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2902
Practice Address - Country:US
Practice Address - Phone:801-826-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No104100000XBehavioral Health & Social Service ProvidersSocial Worker