Provider Demographics
NPI:1215182795
Name:WISE, KIRT DON (LCSW)
Entity Type:Individual
Prefix:MR
First Name:KIRT
Middle Name:DON
Last Name:WISE
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W 2600 S
Mailing Address - Street 2:STE 200
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7784
Mailing Address - Country:US
Mailing Address - Phone:801-815-3443
Mailing Address - Fax:801-776-4162
Practice Address - Street 1:387 E 450 S
Practice Address - Street 2:
Practice Address - City:CLEARFIELD
Practice Address - State:UT
Practice Address - Zip Code:84015-1734
Practice Address - Country:US
Practice Address - Phone:801-635-5022
Practice Address - Fax:801-773-9152
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5666130-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical