Healthcare Provider Details

I. General information

NPI: 1205509429
Provider Name (Legal Business Name): KRISTINA IRENE SUORSA-JOHNSON PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTINA IRENE SUORSA PHD

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 N MARIO CAPECCHI DR
SALT LAKE CITY UT
84113-1125
US

IV. Provider business mailing address

815 E ROWLEY DR
MILLCREEK UT
84107-3028
US

V. Phone/Fax

Practice location:
  • Phone: 801-662-1000
  • Fax:
Mailing address:
  • Phone: 401-864-5906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number12196719-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: