Provider Demographics
NPI:1699411850
Name:TIBURCIO, LAURA G (CSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:G
Last Name:TIBURCIO
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3269 S MAIN ST STE 230
Mailing Address - Street 2:
Mailing Address - City:SOUTH SALT LAKE
Mailing Address - State:UT
Mailing Address - Zip Code:84115-3769
Mailing Address - Country:US
Mailing Address - Phone:801-935-4447
Mailing Address - Fax:
Practice Address - Street 1:3269 S MAIN ST STE 230
Practice Address - Street 2:
Practice Address - City:SOUTH SALT LAKE
Practice Address - State:UT
Practice Address - Zip Code:84115-3769
Practice Address - Country:US
Practice Address - Phone:801-935-4447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
UT13027098-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical