Provider Demographics
NPI:1619287208
Name:SUGERMAN-HERMANSEN, LISA MICHELLE (PHD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:SUGERMAN-HERMANSEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MICHELLE
Other - Last Name:SUGERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:3838 S 700 E STE 101
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1494
Mailing Address - Country:US
Mailing Address - Phone:801-716-4284
Mailing Address - Fax:801-433-0691
Practice Address - Street 1:3838 S 700 E STE 101
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-1494
Practice Address - Country:US
Practice Address - Phone:801-716-4284
Practice Address - Fax:801-433-0691
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-15
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6278375-2501103TC0700X, 103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical