Healthcare Provider Details

I. General information

NPI: 1881237121
Provider Name (Legal Business Name): ELIZABETH DEWITT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2019
Last Update Date: 06/27/2022
Certification Date: 06/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 S 500 E
SALT LAKE CITY UT
84102-2705
US

IV. Provider business mailing address

440 S 500 E
SALT LAKE CITY UT
84102-2705
US

V. Phone/Fax

Practice location:
  • Phone: 801-359-8862
  • Fax:
Mailing address:
  • Phone: 913-230-3613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number11420211-3904
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: