Healthcare Provider Details

I. General information

NPI: 1700567799
Provider Name (Legal Business Name): CORINNA FITZWATER CMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1398 E LUCK LN
MILLCREEK UT
84106-2944
US

IV. Provider business mailing address

4659 S QUAIL VISTA LN APT K
SALT LAKE CITY UT
84117-4864
US

V. Phone/Fax

Practice location:
  • Phone: 801-251-6767
  • Fax:
Mailing address:
  • Phone: 801-971-4866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11291192-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: