Provider Demographics
NPI:1235457094
Name:FENWICK, NICOLE MANON (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MANON
Last Name:FENWICK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 BRICKYARD RD
Mailing Address - Street 2:SUITE #109
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-2560
Mailing Address - Country:US
Mailing Address - Phone:801-746-4334
Mailing Address - Fax:
Practice Address - Street 1:1111 BRICKYARD RD
Practice Address - Street 2:SUITE #109
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84106-2560
Practice Address - Country:US
Practice Address - Phone:801-746-4334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-04
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT500392935011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical