Provider Demographics
NPI:1417235284
Name:CHERYL KELSTROM-SMITH LCSW, LLC
Entity Type:Organization
Organization Name:CHERYL KELSTROM-SMITH LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:KELSTROM-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:801-475-0402
Mailing Address - Street 1:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-0213
Mailing Address - Country:US
Mailing Address - Phone:801-475-0402
Mailing Address - Fax:801-475-7464
Practice Address - Street 1:5149 S 1500 W
Practice Address - Street 2:
Practice Address - City:RIVERDALE
Practice Address - State:UT
Practice Address - Zip Code:84405-3926
Practice Address - Country:US
Practice Address - Phone:801-475-0402
Practice Address - Fax:801-475-7464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-28
Last Update Date:2011-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4730671-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT12/19/1949OtherBIRTHDAY
UTSKYLEROtherDOG