Provider Demographics
NPI:1821349739
Name:SELFRIDGE, WILLIAM J JR (LCSW)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:J
Last Name:SELFRIDGE
Suffix:JR
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2480 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-3058
Mailing Address - Country:US
Mailing Address - Phone:801-706-1467
Mailing Address - Fax:801-435-3750
Practice Address - Street 1:2480 S MAIN ST
Practice Address - Street 2:# 205
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-3058
Practice Address - Country:US
Practice Address - Phone:801-706-1467
Practice Address - Fax:801-435-3750
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT356125-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical