Healthcare Provider Details

I. General information

NPI: 1679771224
Provider Name (Legal Business Name): JANINE WANLASS PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S 400 E SUITE 121E
SALT LAKE CITY UT
84111-2908
US

IV. Provider business mailing address

1641 GARFIELD AVE
SALT LAKE CITY UT
84105-3810
US

V. Phone/Fax

Practice location:
  • Phone: 801-328-9204
  • Fax:
Mailing address:
  • Phone: 801-487-4403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number363402-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: