Provider Demographics
NPI:1437842911
Name:WENNERHOLM, TRACI
Entity Type:Individual
Prefix:
First Name:TRACI
Middle Name:
Last Name:WENNERHOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2066 E LONSDALE DR
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84121-4918
Mailing Address - Country:US
Mailing Address - Phone:801-472-9890
Mailing Address - Fax:
Practice Address - Street 1:2625 E NEWCASTLE DR
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84093-2880
Practice Address - Country:US
Practice Address - Phone:801-826-9175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool