Provider Demographics
NPI:1891296349
Name:LEDBETTER, STUART MICHAEL (SSW)
Entity Type:Individual
Prefix:
First Name:STUART
Middle Name:MICHAEL
Last Name:LEDBETTER
Suffix:
Gender:M
Credentials:SSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 E WESTMINSTER AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-3218
Mailing Address - Country:US
Mailing Address - Phone:801-518-2052
Mailing Address - Fax:
Practice Address - Street 1:8781 S REDWOOD RD BLDG 3
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-9204
Practice Address - Country:US
Practice Address - Phone:385-468-4617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-21
Last Update Date:2018-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT289130-3503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker