Provider Demographics
NPI:1750890935
Name:SUSAN IMHOFF BIRD
Entity type:Organization
Organization Name:SUSAN IMHOFF BIRD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:IMHOFF
Authorized Official - Last Name:BIRD
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-541-5205
Mailing Address - Street 1:2185 E 1700 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2716
Mailing Address - Country:US
Mailing Address - Phone:801-541-5205
Mailing Address - Fax:
Practice Address - Street 1:4505 S WASATCH BLVD STE 320
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-4755
Practice Address - Country:US
Practice Address - Phone:801-541-5205
Practice Address - Fax:801-541-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT288938-3501261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center