Provider Demographics
NPI:1073110805
Name:WIMMER, MAXWELL KAHANA (CSW)
Entity Type:Individual
Prefix:
First Name:MAXWELL
Middle Name:KAHANA
Last Name:WIMMER
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:359 E 1200 S STE 359
Mailing Address - Street 2:
Mailing Address - City:OREM
Mailing Address - State:UT
Mailing Address - Zip Code:84058-6904
Mailing Address - Country:US
Mailing Address - Phone:801-921-1200
Mailing Address - Fax:
Practice Address - Street 1:359 E 1200 S STE 359
Practice Address - Street 2:
Practice Address - City:OREM
Practice Address - State:UT
Practice Address - Zip Code:84058-6904
Practice Address - Country:US
Practice Address - Phone:801-921-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-05
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12879849-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical