Provider Demographics
NPI:1831517119
Name:KELLY LECLUYSE, CHRISTINA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CHRISTINA
Middle Name:
Last Name:KELLY LECLUYSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:MICHELLE
Other - Last Name:LECLUYSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1578 W 1700 S
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84104-3470
Mailing Address - Country:US
Mailing Address - Phone:801-972-2711
Mailing Address - Fax:
Practice Address - Street 1:1578 W 1700 S
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-3470
Practice Address - Country:US
Practice Address - Phone:801-972-2711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-02
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6213977-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical