Provider Demographics
NPI:1851634968
Name:DEWITT, TARA JO
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:JO
Last Name:DEWITT
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 1:5698 W GLEN EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84128-4013
Mailing Address - Country:US
Mailing Address - Phone:801-969-4181
Mailing Address - Fax:
Practice Address - Street 1:4460 S HIGHLAND DR STE 230
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3550
Practice Address - Country:US
Practice Address - Phone:888-949-4864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
UT8630226-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker