Provider Demographics
NPI:1699386441
Name:LODERUP, CHRISTOFFER LAYTON
Entity type:Individual
Prefix:
First Name:CHRISTOFFER
Middle Name:LAYTON
Last Name:LODERUP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2319 FOOTHILL DR, SUITE #240
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84109
Mailing Address - Country:US
Mailing Address - Phone:801-203-0082
Mailing Address - Fax:
Practice Address - Street 1:2319 FOOTHILL DR, SUITE #240
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84109
Practice Address - Country:US
Practice Address - Phone:801-203-0082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14044069-35011041C0700X
101YM0800X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health