Provider Demographics
NPI:1861056343
Name:VANWAGONER, MITCHEL JAY
Entity type:Individual
Prefix:
First Name:MITCHEL
Middle Name:JAY
Last Name:VANWAGONER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12608 S 125 W STE E
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-8437
Mailing Address - Country:US
Mailing Address - Phone:801-679-6669
Mailing Address - Fax:
Practice Address - Street 1:12608 S 125 W STE E
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-8437
Practice Address - Country:US
Practice Address - Phone:801-679-6669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-30
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
UT11780474-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator