Provider Demographics
NPI:1073118998
Name:HENRY, SUZANNE LATRICE (LCSW)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:LATRICE
Last Name:HENRY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2529 E 1300 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1944
Mailing Address - Country:US
Mailing Address - Phone:801-450-0391
Mailing Address - Fax:
Practice Address - Street 1:240 MORRIS AVE
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-3277
Practice Address - Country:US
Practice Address - Phone:801-587-8007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-30
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6268756-3501104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty