Healthcare Provider Details

I. General information

NPI: 1841468147
Provider Name (Legal Business Name): NANCY LARSSON BELLISTON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 02/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 S STATE ST SUITE G-1
OREM UT
84058-6354
US

IV. Provider business mailing address

111 E 5600 S #318
MURRAY UT
84107-6174
US

V. Phone/Fax

Practice location:
  • Phone: 801-802-8608
  • Fax: 801-221-1042
Mailing address:
  • Phone: 801-268-2887
  • Fax: 801-268-4295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5962026-3501
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: