Provider Demographics
NPI:1386153534
Name:BIRD, SUSAN IMHOFF (LCSW)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:IMHOFF
Last Name:BIRD
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 1:2185 E 1700 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2716
Mailing Address - Country:US
Mailing Address - Phone:801-541-5205
Mailing Address - Fax:
Practice Address - Street 1:4505 S WASATCH BLVD STE 320
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-4755
Practice Address - Country:US
Practice Address - Phone:801-541-5205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT288938-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical