Provider Demographics
NPI:1821076803
Name:KOLDEWYN, DAVID COOP (LCSW)
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:COOP
Last Name:KOLDEWYN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 OMNI AVE
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84116-4600
Mailing Address - Country:US
Mailing Address - Phone:801-322-3136
Mailing Address - Fax:
Practice Address - Street 1:195 W 7200 S
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-3703
Practice Address - Country:US
Practice Address - Phone:801-565-6900
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT29487535011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT311135OtherDESERET MUTUAL
UT942938348K01OtherEDUCATORS MUTUAL
UT107001586101OtherINTERMOUNTAIN HEALTH CARE