Provider Demographics
NPI:1487676847
Name:LEITKO, CAROLYN SASICH (LCSW)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SASICH
Last Name:LEITKO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:LEITKO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:1250 EAST 3900 SOUTH
Mailing Address - Street 2:SUITE 260
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-1371
Mailing Address - Country:US
Mailing Address - Phone:801-265-2000
Mailing Address - Fax:801-265-2008
Practice Address - Street 1:1250 E 3900 S
Practice Address - Street 2:SUITE 260
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1348
Practice Address - Country:US
Practice Address - Phone:801-265-2000
Practice Address - Fax:801-265-2008
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13826835011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTQ06257Medicare UPIN