Healthcare Provider Details

I. General information

NPI: 1235267667
Provider Name (Legal Business Name): VICTOR MANUEL ZIZUMBO JR. LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 06/25/2020
Certification Date: 06/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 RSI DR UNIT OFFICEB
LOGAN UT
84321-2203
US

IV. Provider business mailing address

155 W 470 N
SMITHFIELD UT
84335-1732
US

V. Phone/Fax

Practice location:
  • Phone: 435-258-8409
  • Fax:
Mailing address:
  • Phone: 435-258-8409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6418572-3502
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: