Provider Demographics
NPI:1962746719
Name:WASATCH PEDIATRIC NEUROPSYCHOLOGY
Entity type:Organization
Organization Name:WASATCH PEDIATRIC NEUROPSYCHOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NEUROPSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIEN
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:801-596-2347
Mailing Address - Street 1:231 E 400 S
Mailing Address - Street 2:340
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2830
Mailing Address - Country:US
Mailing Address - Phone:801-596-2347
Mailing Address - Fax:801-596-2302
Practice Address - Street 1:231 E 400 S
Practice Address - Street 2:340
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2830
Practice Address - Country:US
Practice Address - Phone:801-596-2347
Practice Address - Fax:801-596-2302
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-18
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2740632501261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)