Provider Demographics
NPI:1427448851
Name:T ISHIMATSU PLLC
Entity type:Organization
Organization Name:T ISHIMATSU PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/AGENT
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:ISHIMATSU
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-550-5428
Mailing Address - Street 1:PO BOX 702184
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84170-2184
Mailing Address - Country:US
Mailing Address - Phone:801-550-5428
Mailing Address - Fax:801-964-6003
Practice Address - Street 1:2832 W 4700 S
Practice Address - Street 2:SUITE B
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-2155
Practice Address - Country:US
Practice Address - Phone:801-550-5428
Practice Address - Fax:801-964-6003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-23
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT33592435011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty