Healthcare Provider Details

I. General information

NPI: 1245991009
Provider Name (Legal Business Name): CARL SALLEE PSYD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2022
Last Update Date: 01/04/2022
Certification Date: 01/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 S 1000 E STE 201
SALT LAKE CITY UT
84102-1403
US

IV. Provider business mailing address

50 W GROVE AVE
SALT LAKE CITY UT
84115-2012
US

V. Phone/Fax

Practice location:
  • Phone: 801-419-0139
  • Fax:
Mailing address:
  • Phone: 970-779-9026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number12375696-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: