Healthcare Provider Details

I. General information

NPI: 1407135718
Provider Name (Legal Business Name): VICTORIA THOMPSON LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA STANGER

II. Dates (important events)

Enumeration Date: 08/04/2011
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 S 2000 W STE A105
SYRACUSE UT
84075-9612
US

IV. Provider business mailing address

618 S 1550 W
SYRACUSE UT
84075-8117
US

V. Phone/Fax

Practice location:
  • Phone: 801-628-6397
  • Fax:
Mailing address:
  • Phone: 801-628-6397
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8357864-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1558439117
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: