Provider Demographics
NPI:1497300248
Name:SMITH, SAMANTHA LEIGH
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:LEIGH
Last Name:SMITH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S 400 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-2905
Mailing Address - Country:US
Mailing Address - Phone:801-582-5534
Mailing Address - Fax:801-582-5540
Practice Address - Street 1:350 S 400 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-2905
Practice Address - Country:US
Practice Address - Phone:801-582-5534
Practice Address - Fax:801-582-5540
Is Sole Proprietor?:No
Enumeration Date:2019-08-08
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10960982-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist