Provider Demographics
NPI:1356301154
Name:WHITEHEAD-SAMPINOS, HEATHER ANNA (LCSW)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:ANNA
Last Name:WHITEHEAD-SAMPINOS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:A
Other - Last Name:WHITEHEAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1839 E 2100 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-4166
Mailing Address - Country:US
Mailing Address - Phone:801-598-4935
Mailing Address - Fax:
Practice Address - Street 1:2500 S STATE ST
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3164
Practice Address - Country:US
Practice Address - Phone:385-646-0569
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2022-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT128651-35011041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12865135000001OtherBLUE CROSS