Provider Demographics
NPI:1518579309
Name:PIERCE, ELISA KACZKA (LCSW)
Entity Type:Individual
Prefix:
First Name:ELISA
Middle Name:KACZKA
Last Name:PIERCE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:ELISA
Other - Middle Name:KACZKA
Other - Last Name:PIERCE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:4773 S BRON BRECK ST
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-6413
Mailing Address - Country:US
Mailing Address - Phone:801-694-6328
Mailing Address - Fax:
Practice Address - Street 1:525 E 100 S STE 5000
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1992
Practice Address - Country:US
Practice Address - Phone:801-581-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-21
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10927777-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical