MEDICARE: LISA DANIELS

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	103TC2200X	Clinical Child & Adolescent Psychologist	95189262504	UT

General Provider Information

NPI Number	:	1477913762
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA DANIELS

Provider Business Mailing Address
First Line	:	4568 S HIGHLAND DR STE 260B
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4236
Country	:	US
Telephone Number	:	435-538-9899
Fax Number	:	801-355-4355

Provider Business Practice Location Address
First Line	:	4568 S HIGHLAND DR STE 260B
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-4236
Country	:	US
Telephone Number	:	435-538-9899
Fax Number	:	801-355-4355

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

Provider Enumeration Date	:	02/29/2016
Last Update Date	:	09/02/2020

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