MEDICARE: DR. LISA L ANSEL PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	53926	MS
2	103TC2200X	Clinical Child & Adolescent Psychologist	53926	MS
3	103TC0700X	Clinical Psychologist	8073852-2501	UT

General Provider Information

NPI Number	:	1184970642
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA L ANSEL PH.D.

Provider Business Mailing Address
First Line	:	879 E 1510 N
Second Line	:
City	:	NORTH OGDEN
State	:	UT
Zip	:	84404-7770
Country	:	US
Telephone Number	:	228-200-1100
Fax Number	:	228-200-1097

Provider Business Practice Location Address
First Line	:	7533 S CENTER VIEW CT STE R
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84084-5526
Country	:	US
Telephone Number	:	228-200-1100
Fax Number	:	228-200-1097

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2012
Last Update Date	:	06/02/2025

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