Provider Demographics
NPI:1326474446
Name:GOLUB, LATEISHA LYNN
Entity Type:Individual
Prefix:
First Name:LATEISHA
Middle Name:LYNN
Last Name:GOLUB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LATEISHA
Other - Middle Name:L
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:4000 S 700 E STE 9
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-2581
Mailing Address - Country:US
Mailing Address - Phone:801-639-9544
Mailing Address - Fax:
Practice Address - Street 1:9176 S 300 W
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-2668
Practice Address - Country:US
Practice Address - Phone:801-520-5749
Practice Address - Fax:801-478-5869
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT897419635011041C0700X
UT8974196-3502104100000X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1326474446Medicaid