Basic Information
| Provider Information | |||||||||
| NPI: | 1487676847 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEITKO | ||||||||
| FirstName: | CAROLYN | ||||||||
| MiddleName: | SASICH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEITKO | ||||||||
| OtherFirstName: | CAROLYN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1250 EAST 3900 SOUTH | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012652000 | ||||||||
| FaxNumber: | 8012652008 | ||||||||
| Practice Location | |||||||||
| Address1: | 1250 E 3900 S | ||||||||
| Address2: | SUITE 260 | ||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841241348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012652000 | ||||||||
| FaxNumber: | 8012652008 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 1382683501 | UT | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.