Provider Demographics
NPI:1730150210
Name:ISHIMATSU, TAMMI Y (LCSW)
Entity type:Individual
Prefix:
First Name:TAMMI
Middle Name:Y
Last Name:ISHIMATSU
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TAMMARA
Other - Middle Name:Y
Other - Last Name:ISHIMATSU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 702184
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84170-2184
Mailing Address - Country:US
Mailing Address - Phone:801-550-5428
Mailing Address - Fax:801-964-6003
Practice Address - Street 1:2832 W 4700 S
Practice Address - Street 2:SUITE B
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-2155
Practice Address - Country:US
Practice Address - Phone:801-550-5428
Practice Address - Fax:801-964-6003
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2015-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT335924-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT33592435000001OtherBLUE CROSS
UTNPP000Medicare UPIN