Healthcare Provider Details

I. General information

NPI: 1194560615
Provider Name (Legal Business Name): GEORGE ALFRED LEBOEUF III LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2024
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 W 9000 S STE 104
SANDY UT
84070-2008
US

IV. Provider business mailing address

140 W 2100 S STE 140
SALT LAKE CITY UT
84115-1852
US

V. Phone/Fax

Practice location:
  • Phone: 385-722-4431
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number13946847-4701
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13946847-3501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number16063
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSWB-2025-1293
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: