Provider Demographics
NPI:1487814018
Name:DEREZOTES, DAVID SCOTT (LCSW, PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:SCOTT
Last Name:DEREZOTES
Suffix:
Gender:M
Credentials:LCSW, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3669 OAKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3327
Mailing Address - Country:US
Mailing Address - Phone:801-585-3546
Mailing Address - Fax:801-585-3219
Practice Address - Street 1:3669 OAKVIEW DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3327
Practice Address - Country:US
Practice Address - Phone:801-585-3546
Practice Address - Fax:801-585-3219
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-17
Last Update Date:2008-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13819235011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical