Provider Demographics
NPI:1003304148
Name:SLADE, MICHAEL KEITH (MSW)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:KEITH
Last Name:SLADE
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4660 S BROOKWILLOW CV APT F
Mailing Address - Street 2:
Mailing Address - City:MILLCREEK
Mailing Address - State:UT
Mailing Address - Zip Code:84117-8030
Mailing Address - Country:US
Mailing Address - Phone:801-830-8643
Mailing Address - Fax:
Practice Address - Street 1:2872 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-3147
Practice Address - Country:US
Practice Address - Phone:801-485-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical