Provider Demographics
NPI:1215197264
Name:LEISHMAN, LARA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LARA
Middle Name:
Last Name:LEISHMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 E 400 S
Mailing Address - Street 2:
Mailing Address - City:SLC
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2830
Mailing Address - Country:US
Mailing Address - Phone:801-363-1189
Mailing Address - Fax:801-363-1198
Practice Address - Street 1:231 E 400 S
Practice Address - Street 2:
Practice Address - City:SLC
Practice Address - State:UT
Practice Address - Zip Code:84111-2830
Practice Address - Country:US
Practice Address - Phone:801-363-1189
Practice Address - Fax:801-363-1198
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2014-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6295108-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist