Healthcare Provider Details

I. General information

NPI: 1609964659
Provider Name (Legal Business Name): LESLIE M. WHITE MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 HIGHLAND DR STE 210
SALT LAKE CITY UT
84124-2674
US

IV. Provider business mailing address

4190 HIGHLAND DR STE 210
SALT LAKE CITY UT
84124-2674
US

V. Phone/Fax

Practice location:
  • Phone: 801-278-8859
  • Fax: 801-278-8504
Mailing address:
  • Phone: 801-278-8859
  • Fax: 801-278-8504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number122349-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier122349-3501
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerCLINICAL SOCIAL WORKER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: