Provider Demographics
NPI:1407288145
Name:GOTBERG, NICOLE M (SSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:GOTBERG
Suffix:
Gender:F
Credentials:SSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 N 1950 W
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-3100
Mailing Address - Country:US
Mailing Address - Phone:385-315-3237
Mailing Address - Fax:
Practice Address - Street 1:195 N 1950 W
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84116-3100
Practice Address - Country:US
Practice Address - Phone:801-538-4001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-05
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253J00000X
UT9450078-3503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No253J00000XAgenciesFoster Care Agency