Provider Demographics
NPI:1023683562
Name:BAILEY, STEPHANIE (MED)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:
Last Name:BAILEY
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4506 SOUTH LARCH WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84123
Mailing Address - Country:US
Mailing Address - Phone:801-671-6308
Mailing Address - Fax:
Practice Address - Street 1:2500 S STATE ST
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3164
Practice Address - Country:US
Practice Address - Phone:385-646-9853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-26
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program