Healthcare Provider Details

I. General information

NPI: 1093005308
Provider Name (Legal Business Name): ELIZABETH DOSHER LCSW
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2011
Last Update Date: 09/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2760 RASMUSSEN RD BLDG D SUITE 205
PARK CITY UT
84098-5684
US

IV. Provider business mailing address

2760 W EST RASMUSSEN RD, BLDG D SUITE 205
PARK CITY UT
84098-5177
US

V. Phone/Fax

Practice location:
  • Phone: 435-513-2280
  • Fax:
Mailing address:
  • Phone: 435-513-2280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number62245433501
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number62245433501
License Number StateUT

VIII. Authorized Official

Name: ELIZABETH ANN DOSHER
Title or Position: OWNER/PSYCHOTHERAPIST
Credential: LCSW
Phone: 435-513-2280