Healthcare Provider Details

I. General information

NPI: 1043833460
Provider Name (Legal Business Name): MARY ELIZABETH ANDOLSEK LCSW,CT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/20/2020
Last Update Date: 05/20/2020
Certification Date: 05/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5411 S VINE ST # 6
MURRAY UT
84107-7746
US

IV. Provider business mailing address

1319 S ROXBURY RD
SALT LAKE CITY UT
84108-2455
US

V. Phone/Fax

Practice location:
  • Phone: 801-783-8401
  • Fax:
Mailing address:
  • Phone: 801-783-8401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number9899228-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: