Healthcare Provider Details

I. General information

NPI: 1326870106
Provider Name (Legal Business Name): ZIOMARA M CERVANTES PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

GEORGE E WAHLEN VA MEDICAL CENTER 500 FOOTHILL DRIVE
SALT LAKE CITY UT
84148-0001
US

IV. Provider business mailing address

134 S 400 E APT 105
SALT LAKE CITY UT
84111-2161
US

V. Phone/Fax

Practice location:
  • Phone: 801-582-1565
  • Fax:
Mailing address:
  • Phone: 612-356-4420
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number135767402501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: