Provider Demographics
NPI:1275769259
Name:BOLLOW, SUSAN MICHELLE (LCSW)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:MICHELLE
Last Name:BOLLOW
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:MICHELLE
Other - Last Name:CANABE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:827 E WILMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1821
Mailing Address - Country:US
Mailing Address - Phone:385-321-3109
Mailing Address - Fax:
Practice Address - Street 1:4444 S 700 E STE 102
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84107-3075
Practice Address - Country:US
Practice Address - Phone:385-321-3109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7046059-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1275769259Medicaid