Provider Demographics
NPI:1457465460
Name:IMPERIAL, DOROTHY L (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:DOROTHY
Middle Name:L
Last Name:IMPERIAL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 71736
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-0736
Mailing Address - Country:US
Mailing Address - Phone:801-944-4092
Mailing Address - Fax:
Practice Address - Street 1:699 E SOUTH TEMPLE
Practice Address - Street 2:SUITE 300
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1142
Practice Address - Country:US
Practice Address - Phone:801-631-3926
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5121495-3501101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107035592101OtherIHC
UT82597OtherPEHP P33
UT51214953501001OtherBCBS
UT885542OtherDMBA P33
UTQ53385Medicare UPIN