Provider Demographics
NPI:1558714261
Name:ELISH, KATIE (LMLP)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:ELISH
Suffix:
Gender:F
Credentials:LMLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:316-978-3086
Practice Address - Street 1:5770 S 1500 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84123-5216
Practice Address - Country:US
Practice Address - Phone:801-313-7770
Practice Address - Fax:801-313-7771
Is Sole Proprietor?:No
Enumeration Date:2016-07-18
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2701103TB0200X
UT10946698-2501103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral