Provider Demographics
NPI:1790755643
Name:ATTALLAH, TAMMER MAHMOUD (LCSW)
Entity Type:Individual
Prefix:MR
First Name:TAMMER
Middle Name:MAHMOUD
Last Name:ATTALLAH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:MR
Other - First Name:TAMMER
Other - Middle Name:M
Other - Last Name:ATTALLAH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:3809 W 6200 S
Mailing Address - Street 2:
Mailing Address - City:KEARNS
Mailing Address - State:UT
Mailing Address - Zip Code:84118-3725
Mailing Address - Country:US
Mailing Address - Phone:801-560-1548
Mailing Address - Fax:
Practice Address - Street 1:3809 W 6200 S
Practice Address - Street 2:
Practice Address - City:KEARNS
Practice Address - State:UT
Practice Address - Zip Code:84118-3725
Practice Address - Country:US
Practice Address - Phone:801-560-1548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT288112535011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2881253501OtherLCSW LICENSE
UT1041C0700XOtherTAXONOMY #
UT28812535001001OtherBLUE CROSS