Provider Demographics
NPI:1255168647
Name:ONTIVEROS, KRISTEN ANN (CSW)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ANN
Last Name:ONTIVEROS
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:ANN
Other - Last Name:LAFON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:350 E 400 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2993
Mailing Address - Country:US
Mailing Address - Phone:801-413-3740
Mailing Address - Fax:
Practice Address - Street 1:350 E 400 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2993
Practice Address - Country:US
Practice Address - Phone:801-413-3740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10532887-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker