Healthcare Provider Details

I. General information

NPI: 1689519134
Provider Name (Legal Business Name): THERESA IPOLITO LCSW PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

688 E 3RD AVE
SALT LAKE CITY UT
84103-3452
US

IV. Provider business mailing address

688 E 3RD AVE
SALT LAKE CITY UT
84103-3452
US

V. Phone/Fax

Practice location:
  • Phone: 716-725-8542
  • Fax:
Mailing address:
  • Phone: 716-725-8542
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: THERESA IPOLITO
Title or Position: OWNER/THERPIST
Credential: LCSW
Phone: 716-725-8542