Provider Demographics
NPI:1164903670
Name:WILHELMSEN, SETH ROGER (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:SETH
Middle Name:ROGER
Last Name:WILHELMSEN
Suffix:
Gender:M
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:651 LAVINA DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-3811
Mailing Address - Country:US
Mailing Address - Phone:801-668-8206
Mailing Address - Fax:
Practice Address - Street 1:2985 N 935 E STE 7
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84040
Practice Address - Country:US
Practice Address - Phone:801-771-0273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-23
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTRBT-18-63729106S00000X
UT1-19-39930103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1578983318Medicaid