Healthcare Provider Details

I. General information

NPI: 1952812414
Provider Name (Legal Business Name): LAUREN MICHELE WEITZMAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 S 1100 E STE 303
SALT LAKE CITY UT
84102-4307
US

IV. Provider business mailing address

579 E 13TH AVE
SALT LAKE CITY UT
84103-3234
US

V. Phone/Fax

Practice location:
  • Phone: 801-680-2941
  • Fax:
Mailing address:
  • Phone: 801-680-2941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number287222-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: