Provider Demographics
NPI:1720001951
Name:CUNLIFFE, LISA (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CUNLIFFE
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 1:4403 HARRISON BLVD STE 700A
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3295
Mailing Address - Country:US
Mailing Address - Phone:801-387-5337
Mailing Address - Fax:801-387-5336
Practice Address - Street 1:4403 HARRISON BLVD STE 700A
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-3295
Practice Address - Country:US
Practice Address - Phone:801-387-5337
Practice Address - Fax:801-387-5336
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT26420835011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000059508Medicare PIN