Healthcare Provider Details

I. General information

NPI: 1093293425
Provider Name (Legal Business Name): ANGELA SAKELLARIOU LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2018
Last Update Date: 09/26/2024
Certification Date: 09/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48TH MDG UNIT 5115
APO AE
09461-5115
US

IV. Provider business mailing address

4410 S LOREN VON DR
SALT LAKE CITY UT
84124-3819
US

V. Phone/Fax

Practice location:
  • Phone: 314-226-8603
  • Fax:
Mailing address:
  • Phone: 801-949-0879
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9761389-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: