Provider Demographics
NPI:1700198462
Name:TAHOLO, LEILANI ANNE (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:LEILANI
Middle Name:ANNE
Last Name:TAHOLO
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 1:1578 W 1700 S
Mailing Address - Street 2:#200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-3470
Mailing Address - Country:US
Mailing Address - Phone:801-972-2711
Mailing Address - Fax:801-972-2709
Practice Address - Street 1:1578 W 1700 S
Practice Address - Street 2:#200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-3470
Practice Address - Country:US
Practice Address - Phone:801-972-2711
Practice Address - Fax:801-972-2709
Is Sole Proprietor?:No
Enumeration Date:2010-07-10
Last Update Date:2010-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13683435011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical