Healthcare Provider Details

I. General information

NPI: 1386368157
Provider Name (Legal Business Name): KATHLEEN MARIA ATENCIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2022
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 E 100 S
SALT LAKE CITY UT
84111-1700
US

IV. Provider business mailing address

344 E 100 S
SALT LAKE CITY UT
84111-1700
US

V. Phone/Fax

Practice location:
  • Phone: 801-428-4257
  • Fax:
Mailing address:
  • Phone: 801-428-4257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13991296-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number13991296-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: