Provider Demographics
NPI:1669715041
Name:MACCEO, IDANNA
Entity type:Individual
Prefix:
First Name:IDANNA
Middle Name:
Last Name:MACCEO
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 1:5965 S 900 E
Mailing Address - Street 2:STE 430
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-1720
Mailing Address - Country:US
Mailing Address - Phone:801-743-6175
Mailing Address - Fax:801-747-7890
Practice Address - Street 1:5965 S 900 E
Practice Address - Street 2:STE 240
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121-1720
Practice Address - Country:US
Practice Address - Phone:801-743-6175
Practice Address - Fax:801-747-7890
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor