MEDICARE: DR. KATHERINE THOMAS FORTENBERRY PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TH0004X	Health Psychologist	50871	MS
2	103TC0700X	Clinical Psychologist	50871	MS
3	103TH0004X	Health Psychologist	8106647-2501	UT
4	103TC0700X	Clinical Psychologist	8106647-2501	UT

General Provider Information

NPI Number	:	1982902185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KATHERINE THOMAS FORTENBERRY PH.D.

Provider Business Mailing Address
First Line	:	375 CHIPETA WAY
Second Line	:	SUITE A
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1260
Country	:	US
Telephone Number	:	801-587-3379
Fax Number	:

Provider Business Practice Location Address
First Line	:	375 CHIPETA WAY
Second Line	:	SUITE A
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-1260
Country	:	US
Telephone Number	:	801-587-3379
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/11/2011
Last Update Date	:	10/28/2021

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