Provider Demographics
NPI:1336716851
Name:DOVE, MARY (SSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DOVE
Suffix:
Gender:F
Credentials:SSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:523 HERITAGE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-5711
Mailing Address - Country:US
Mailing Address - Phone:385-429-3991
Mailing Address - Fax:801-525-6984
Practice Address - Street 1:523 HERITAGE PARK BLVD
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5711
Practice Address - Country:US
Practice Address - Phone:385-429-3991
Practice Address - Fax:801-525-6984
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-04
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5484223-3503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty