Healthcare Provider Details

I. General information

NPI: 1164331419
Provider Name (Legal Business Name): ALEXANDREA CLARK DITOLLA CMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALI DITOLLA CMHC

II. Dates (important events)

Enumeration Date: 09/03/2026
Last Update Date: 09/03/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 5600 S STE 200
SALT LAKE CITY UT
84107-8158
US

IV. Provider business mailing address

868 E ROOSEVELT AVE
SALT LAKE CITY UT
84105-2235
US

V. Phone/Fax

Practice location:
  • Phone: 385-346-0031
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number7007392-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: