Basic Information
| Provider Information | |||||||||
| NPI: | 1972111086 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DALAL | ||||||||
| FirstName: | AQSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 241 E ELLEN LN | ||||||||
| Address2: | |||||||||
| City: | NORTH SALT LAKE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840542304 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9361 S 300 E | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840702902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8018265000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2020 | ||||||||
| LastUpdateDate: | 05/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041S0200X | Y | Behavioral Health & Social Service Providers | Social Worker | School |
No ID Information.