Healthcare Provider Details

I. General information

NPI: 1124487053
Provider Name (Legal Business Name): CYNTHIA SUN FONNESBECK MAS-LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2016
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2180 E 4500 S STE 105
HOLLADAY UT
84117-4017
US

IV. Provider business mailing address

2180 E 4500 S STE 105
HOLLADAY UT
84117-4017
US

V. Phone/Fax

Practice location:
  • Phone: 801-416-0862
  • Fax: 801-905-1242
Mailing address:
  • Phone: 801-416-0862
  • Fax: 801-905-1242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number11353631-3902
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: