Provider Demographics
NPI:1770171548
Name:LAUREL ELIZABETH BLACK
Entity type:Organization
Organization Name:LAUREL ELIZABETH BLACK
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LAUREL
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:801-651-8823
Mailing Address - Street 1:447 N 300 W STE 7
Mailing Address - Street 2:
Mailing Address - City:KAYSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84037-4203
Mailing Address - Country:US
Mailing Address - Phone:801-651-8823
Mailing Address - Fax:
Practice Address - Street 1:447 N 300 W STE 7
Practice Address - Street 2:
Practice Address - City:KAYSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84037-4203
Practice Address - Country:US
Practice Address - Phone:801-651-8823
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-06
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1831536325OtherNPI