Provider Demographics
NPI:1548859671
Name:ANKONINA, LIAT (SSW)
Entity type:Individual
Prefix:
First Name:LIAT
Middle Name:
Last Name:ANKONINA
Suffix:
Gender:F
Credentials:SSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 E 5900 S STE 101
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-7256
Mailing Address - Country:US
Mailing Address - Phone:801-261-5790
Mailing Address - Fax:801-261-5794
Practice Address - Street 1:164 E 5900 S STE 101
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84107-7256
Practice Address - Country:US
Practice Address - Phone:801-261-5790
Practice Address - Fax:801-261-5794
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-13
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11378898-3503101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)