Healthcare Provider Details

I. General information

NPI: 1265976195
Provider Name (Legal Business Name): POLIZZI FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2016
Last Update Date: 12/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E 4500 S SUITE G220
SALT LAKE CITY UT
84107-4500
US

IV. Provider business mailing address

515 E 4500 S SUITE G220
SALT LAKE CITY UT
84107-4500
US

V. Phone/Fax

Practice location:
  • Phone: 801-590-9557
  • Fax: 801-590-9957
Mailing address:
  • Phone: 801-590-9557
  • Fax: 801-590-5997

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License Number178852-1205
License Number StateUT

VIII. Authorized Official

Name: MS. LIZ KOCIOLEK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 801-590-9557