Provider Demographics
NPI:1881168185
Name:BARTLEY, KORILYNN CHEATHAM
Entity type:Individual
Prefix:
First Name:KORILYNN
Middle Name:CHEATHAM
Last Name:BARTLEY
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 1:4962 W 7670 S
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-3675
Mailing Address - Country:US
Mailing Address - Phone:801-783-6712
Mailing Address - Fax:
Practice Address - Street 1:124 S 400 E STE 300
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-5307
Practice Address - Country:US
Practice Address - Phone:801-467-2863
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty