Provider Demographics
NPI:1023691151
Name:FORTSON, LEAH M (MD)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:M
Last Name:FORTSON
Suffix:
Gender:F
Credentials:MD
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Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:HUNTSMAN MENTAL HEALTH INSTITUTE/ DEPT OF PSYCHIATRY
Mailing Address - Street 2:501 CHIPETA WAY
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108
Mailing Address - Country:US
Mailing Address - Phone:801-581-4096
Mailing Address - Fax:
Practice Address - Street 1:HUNTSMAN MENTAL HEALTH INSTITUTE
Practice Address - Street 2:501 CHIPETA WAY
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108
Practice Address - Country:US
Practice Address - Phone:801-581-4096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
UT12985848-12052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry