Provider Demographics
NPI:1649358201
Name:SERPAS, DOROTHEE LELIA (PHD)
Entity type:Individual
Prefix:
First Name:DOROTHEE
Middle Name:LELIA
Last Name:SERPAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1088 CLIFF SIDE CT
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-7242
Mailing Address - Country:US
Mailing Address - Phone:801-272-5083
Mailing Address - Fax:
Practice Address - Street 1:2040 MURRAY HOLLADAY RD
Practice Address - Street 2:SUITE 211
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-5185
Practice Address - Country:US
Practice Address - Phone:801-272-5083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT345818-2501103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT475451OtherVENDOR NUMBER