Healthcare Provider Details

I. General information

NPI: 1275769259
Provider Name (Legal Business Name): SUSAN MICHELLE BOLLOW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SUSAN MICHELLE THORN LCSW

II. Dates (important events)

Enumeration Date: 06/04/2009
Last Update Date: 09/06/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4434 S HIGHLAND DR
MILLCREEK UT
84124-3533
US

IV. Provider business mailing address

2734 E CANTON LN
SANDY UT
84092-7125
US

V. Phone/Fax

Practice location:
  • Phone: 385-321-3109
  • Fax:
Mailing address:
  • Phone: 801-574-7077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number7046059-3502
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier1275769259
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: