Healthcare Provider Details

I. General information

NPI: 1699411850
Provider Name (Legal Business Name): LAURA G TIBURCIO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2022
Last Update Date: 07/22/2024
Certification Date: 07/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3269 S MAIN ST STE 100
SOUTH SALT LAKE UT
84115-3773
US

IV. Provider business mailing address

3269 S MAIN ST STE 230
SOUTH SALT LAKE UT
84115-3769
US

V. Phone/Fax

Practice location:
  • Phone: 801-935-4447
  • Fax:
Mailing address:
  • Phone: 801-935-4447
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13027098-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: