Provider Demographics
NPI:1376927830
Name:KOLDITZ, BRANDI (CSW)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:KOLDITZ
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:BRANDI
Other - Middle Name:
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1537 N 3890 W
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-6900
Mailing Address - Country:US
Mailing Address - Phone:435-327-1776
Mailing Address - Fax:
Practice Address - Street 1:4460 S HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-3543
Practice Address - Country:US
Practice Address - Phone:801-263-7100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-15
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12358022-35061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12358022-3502OtherDIVISION OF OCCUPATIONAL & PROFESSIONAL LICENSING
UT1376927830Medicaid