Healthcare Provider Details

I. General information

NPI: 1659351492
Provider Name (Legal Business Name): VICTORIA ANN LIEDTKE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 LAKE PARK BLVD
WEST VALLEY CITY UT
84120-8230
US

IV. Provider business mailing address

2525 LAKE PARK BLVD
WEST VALLEY CITY UT
84120-8230
US

V. Phone/Fax

Practice location:
  • Phone: 801-982-3048
  • Fax: 855-525-7075
Mailing address:
  • Phone: 801-982-3048
  • Fax: 855-525-7075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3480263501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: