Provider Demographics
NPI:1619287208
Name:SUGERMAN, LISA MICHELLE (PHD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:SUGERMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:389 W 10000 S STE A
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-4104
Mailing Address - Country:US
Mailing Address - Phone:801-716-4284
Mailing Address - Fax:801-433-0691
Practice Address - Street 1:389 W 10000 S STE A
Practice Address - Street 2:
Practice Address - City:SOUTH JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84095-4104
Practice Address - Country:US
Practice Address - Phone:801-716-4284
Practice Address - Fax:801-433-0691
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6278375-2501103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical