Provider Demographics
NPI:1619650983
Name:SOUTHICHACK, TAIA (ACMHC)
Entity type:Individual
Prefix:
First Name:TAIA
Middle Name:
Last Name:SOUTHICHACK
Suffix:
Gender:F
Credentials:ACMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:452 N 625 W
Mailing Address - Street 2:
Mailing Address - City:CLEARFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84015-3859
Mailing Address - Country:US
Mailing Address - Phone:801-814-8060
Mailing Address - Fax:
Practice Address - Street 1:64 S 360 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2590
Practice Address - Country:US
Practice Address - Phone:801-449-0017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-11
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13498101-6009101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health