Provider Demographics
NPI:1720492887
Name:FIFE, CASEY PAUL
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:PAUL
Last Name:FIFE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9045 S 1300 E STE 200
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-3134
Mailing Address - Country:US
Mailing Address - Phone:801-666-6834
Mailing Address - Fax:
Practice Address - Street 1:862 S MAIN
Practice Address - Street 2:SUITE 4
Practice Address - City:BRIGHAM CITY
Practice Address - State:UT
Practice Address - Zip Code:84302
Practice Address - Country:US
Practice Address - Phone:435-754-4735
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-17
Last Update Date:2020-10-23
Deactivation Date:2018-06-01
Deactivation Code:
Reactivation Date:2018-07-03
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
UT10590005-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor