Healthcare Provider Details

I. General information

NPI: 1134933757
Provider Name (Legal Business Name): ANNALISA GREGORY CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 08/19/2025
Certification Date: 08/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2655 S LAKE ERIE DR
WEST VALLEY CITY UT
84120-7350
US

IV. Provider business mailing address

4631 S SYCAMORE DR
HOLLADAY UT
84117-5170
US

V. Phone/Fax

Practice location:
  • Phone: 385-321-5516
  • Fax:
Mailing address:
  • Phone: 385-321-5516
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14192019-3502
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number14192019-3503
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: