Provider Demographics
NPI:1871776146
Name:TRONRUD, PHYLLIS M (MC)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:M
Last Name:TRONRUD
Suffix:
Gender:F
Credentials:MC
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:M
Other - Last Name:WAITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1407 N 2000 W
Mailing Address - Street 2:SUITE D
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-8562
Mailing Address - Country:US
Mailing Address - Phone:801-971-5550
Mailing Address - Fax:
Practice Address - Street 1:1407 N 2000 W
Practice Address - Street 2:SUITE D
Practice Address - City:CLINTON
Practice Address - State:UT
Practice Address - Zip Code:84015-8562
Practice Address - Country:US
Practice Address - Phone:801-971-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2016-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6818930-6004101YP2500X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health