Provider Demographics
NPI:1689910895
Name:WHARTON, NICOLE ALISE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:ALISE
Last Name:WHARTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4866 S HIGHLAND CIR
Mailing Address - Street 2:#2
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-6039
Mailing Address - Country:US
Mailing Address - Phone:925-548-6598
Mailing Address - Fax:
Practice Address - Street 1:1760 W 4805 S
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84129-1177
Practice Address - Country:US
Practice Address - Phone:801-955-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-14
Last Update Date:2018-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8066223-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker