Provider Demographics
NPI:1417052515
Name:NICOLAISEN, JOENE FARRIS
Entity Type:Individual
Prefix:
First Name:JOENE
Middle Name:FARRIS
Last Name:NICOLAISEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOENE
Other - Middle Name:FARRIS
Other - Last Name:NICOLAISEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPC
Mailing Address - Street 1:PO BOX 71279
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84171-0279
Mailing Address - Country:US
Mailing Address - Phone:801-313-6814
Mailing Address - Fax:
Practice Address - Street 1:6526 S STATE ST
Practice Address - Street 2:404
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7261
Practice Address - Country:US
Practice Address - Phone:801-313-6814
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5052659-6004101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional