Healthcare Provider Details

I. General information

NPI: 1699386441
Provider Name (Legal Business Name): CHRISTOFFER LAYTON LODERUP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2020
Last Update Date: 06/26/2024
Certification Date: 06/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2319 FOOTHILL DR, SUITE #240
SALT LAKE CITY UT
84109
US

IV. Provider business mailing address

2319 FOOTHILL DR, SUITE #240
SALT LAKE CITY UT
84109
US

V. Phone/Fax

Practice location:
  • Phone: 801-203-0082
  • Fax:
Mailing address:
  • Phone: 801-203-0082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14044069-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: