Healthcare Provider Details

I. General information

NPI: 1043921760
Provider Name (Legal Business Name): LILY HANSCOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2022
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

495 E 4500 S STE 100
SALT LAKE CITY UT
84107-2797
US

IV. Provider business mailing address

495 E 4500 S STE 100
SALT LAKE CITY UT
84107-2797
US

V. Phone/Fax

Practice location:
  • Phone: 801-746-4334
  • Fax: 801-746-4337
Mailing address:
  • Phone: 801-746-4334
  • Fax: 801-746-4337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number14209872-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14209872-6004
License Number StateUT
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14209872-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: