Provider Demographics
NPI:1750826913
Name:KATHLEEN FITZWILLIAM LAKEY LLC
Entity Type:Organization
Organization Name:KATHLEEN FITZWILLIAM LAKEY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:FITZWILLIAM
Authorized Official - Last Name:LAKEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:385-218-8266
Mailing Address - Street 1:275 E SOUTH TEMPLE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84111-1247
Mailing Address - Country:US
Mailing Address - Phone:385-218-8266
Mailing Address - Fax:801-364-1433
Practice Address - Street 1:275 E SOUTH TEMPLE
Practice Address - Street 2:SUITE 101
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1247
Practice Address - Country:US
Practice Address - Phone:385-218-8266
Practice Address - Fax:801-364-1433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-12-27
Last Update Date:2016-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7698951-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty