Provider Demographics
NPI:1871147850
Name:HUBBARD, TAVISH LARISE TRUJILLO (LCSW)
Entity type:Individual
Prefix:
First Name:TAVISH
Middle Name:LARISE TRUJILLO
Last Name:HUBBARD
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:TAVISH
Other - Middle Name:LARISE TRUJILLO
Other - Last Name:HUBBARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5547 W BAILIFF DR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84118-7301
Mailing Address - Country:US
Mailing Address - Phone:801-889-7221
Mailing Address - Fax:
Practice Address - Street 1:5547 W BAILIFF DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84118-7301
Practice Address - Country:US
Practice Address - Phone:801-889-7221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-29
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
UT7907304-35011041C0700X
ORL157311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator