Provider Demographics
NPI:1285842435
Name:VITELA, TAMARA LIN (LCSW)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:LIN
Last Name:VITELA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TAMARA
Other - Middle Name:LIN
Other - Last Name:ISAACS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:865 E 4800 S STE 221
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-5524
Mailing Address - Country:US
Mailing Address - Phone:801-597-9844
Mailing Address - Fax:
Practice Address - Street 1:865 E 4800 S STE 221
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-5524
Practice Address - Country:US
Practice Address - Phone:801-597-9844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-20
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT293289-35011041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA33-1052916OtherTAX ID NUMBER