Provider Demographics
NPI:1417138710
Name:BROSIUS, LESLIE (L C S W)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:BROSIUS
Suffix:
Gender:F
Credentials:L C S W
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7434 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-2014
Mailing Address - Country:US
Mailing Address - Phone:801-566-4423
Mailing Address - Fax:801-566-4779
Practice Address - Street 1:7434 S STATE ST
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-2014
Practice Address - Country:US
Practice Address - Phone:801-566-4423
Practice Address - Fax:801-566-4779
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT554592535011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1417138710OtherBLUE CROSS
UTU000072383Medicare PIN
UTU000073822Medicare PIN