Provider Demographics
NPI:1558351007
Name:EARLE, ELIZABETH ANN (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:ANN
Last Name:EARLE
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:ELIZABETH
Other - Middle Name:
Other - Last Name:EARLE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:9891 BORG DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84092-4120
Mailing Address - Country:US
Mailing Address - Phone:801-403-4631
Mailing Address - Fax:
Practice Address - Street 1:4568 S HIGHLAND DR STE 270
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84117
Practice Address - Country:US
Practice Address - Phone:801-478-2780
Practice Address - Fax:801-478-2781
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT377440-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTR13268OtherSTERLING
UT680012550OtherRAILROAD MEDICARE
UT37744025001001OtherBLUE CROSS BLUE SHIELD