Provider Demographics
NPI:1245557792
Name:LEIFSON, ZACHARY ALBERT (LCSW)
Entity Type:Individual
Prefix:
First Name:ZACHARY
Middle Name:ALBERT
Last Name:LEIFSON
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5685 S 1475 E
Mailing Address - Street 2:#3B
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4716
Mailing Address - Country:US
Mailing Address - Phone:801-582-1565
Mailing Address - Fax:
Practice Address - Street 1:5685 S 1475 E
Practice Address - Street 2:#3B
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403
Practice Address - Country:US
Practice Address - Phone:801-582-1565
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6856471-35011041C0700X
261QM0801X, 261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1245557792Medicaid