Provider Demographics
NPI:1679543185
Name:ATTALLAH, GINA MARIE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:GINA
Middle Name:MARIE
Last Name:ATTALLAH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1795 S 1700 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2970
Mailing Address - Country:US
Mailing Address - Phone:801-971-2845
Mailing Address - Fax:
Practice Address - Street 1:2525 S LAKE PARK BLVD
Practice Address - Street 2:OPTUMHEALTH
Practice Address - City:WEST VALLEY CITY
Practice Address - State:UT
Practice Address - Zip Code:84120-8230
Practice Address - Country:US
Practice Address - Phone:801-982-3064
Practice Address - Fax:801-982-3159
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2012-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT497211435011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT49721143500001OtherBLUE CROSS
UT10704211101OtherINTRMTN. HEALTH CARE