Provider Demographics
NPI:1689178071
Name:FOSTER, MARIE DIAN (MED SPS)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:DIAN
Last Name:FOSTER
Suffix:
Gender:F
Credentials:MED SPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 E 600 N
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84097-4135
Mailing Address - Country:US
Mailing Address - Phone:801-404-0011
Mailing Address - Fax:
Practice Address - Street 1:5455 RIVER RUN DR
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-7726
Practice Address - Country:US
Practice Address - Phone:801-404-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool