Provider Demographics
NPI:1528335619
Name:SAMUELSON, TRUDY LARISSA (CMHC)
Entity type:Individual
Prefix:
First Name:TRUDY
Middle Name:LARISSA
Last Name:SAMUELSON
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 E 4500 S STE 300
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-4502
Mailing Address - Country:US
Mailing Address - Phone:801-261-3500
Mailing Address - Fax:385-500-3690
Practice Address - Street 1:650 E 4500 S STE 300
Practice Address - Street 2:650 E 4500 S STE 300
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-8410
Practice Address - Country:US
Practice Address - Phone:801-261-3500
Practice Address - Fax:385-500-3690
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT51392806004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health