MEDICARE: DR. CYNTHIA E PALACIOS-GUTIERREZ PSY.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	101YM0800X	Mental Health Counselor
2	103TC0700X	Clinical Psychologist	9187320-2501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9187320-2501	OTHER	UT	DIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING

General Provider Information

NPI Number	:	1407160070
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CYNTHIA E PALACIOS-GUTIERREZ PSY.D.

Provider Business Mailing Address
First Line	:	3760 S HIGHLAND DR STE 354
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-4260
Country	:	US
Telephone Number	:	385-260-0181
Fax Number	:

Provider Business Practice Location Address
First Line	:	3760 S HIGHLAND DR STE 354
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-4260
Country	:	US
Telephone Number	:	385-260-0181
Fax Number	:

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

Provider Enumeration Date	:	08/05/2010
Last Update Date	:	11/10/2021

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