Provider Demographics
NPI:1700567799
Name:FITZWATER, CORINNA (CMHC)
Entity type:Individual
Prefix:
First Name:CORINNA
Middle Name:
Last Name:FITZWATER
Suffix:
Gender:F
Credentials:CMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4659 S QUAIL VISTA LN APT K
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-4864
Mailing Address - Country:US
Mailing Address - Phone:801-971-4866
Mailing Address - Fax:
Practice Address - Street 1:1398 E LUCK LN
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84106-2944
Practice Address - Country:US
Practice Address - Phone:801-251-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11291192-6004101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health