Provider Demographics
NPI:1245939479
Name:CANTRELL, CONNIE VISE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:VISE
Last Name:CANTRELL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 S 800 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2910
Mailing Address - Country:US
Mailing Address - Phone:801-578-8108
Mailing Address - Fax:801-578-8111
Practice Address - Street 1:465 S 400 E STE 300
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-3349
Practice Address - Country:US
Practice Address - Phone:801-578-8599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT343113-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist