Provider Demographics
NPI:1881751998
Name:CARCELLI, SUSAN JONES (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:JONES
Last Name:CARCELLI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 150307
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84415-0307
Mailing Address - Country:US
Mailing Address - Phone:801-317-1884
Mailing Address - Fax:801-479-8247
Practice Address - Street 1:425 E 5350 S STE 370
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84405-7410
Practice Address - Country:US
Practice Address - Phone:801-317-1884
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT871141372501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR61017Medicare UPIN