Provider Demographics
NPI:1164241121
Name:KNUDSEN, MICAELA HARLEY
Entity type:Individual
Prefix:
First Name:MICAELA
Middle Name:HARLEY
Last Name:KNUDSEN
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 1:42 E 300 N
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-1859
Mailing Address - Country:US
Mailing Address - Phone:208-240-7178
Mailing Address - Fax:
Practice Address - Street 1:42 E 300 N
Practice Address - Street 2:
Practice Address - City:SPANISH FORK
Practice Address - State:UT
Practice Address - Zip Code:84660-1859
Practice Address - Country:US
Practice Address - Phone:208-240-7178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical