Provider Demographics
NPI:1851723209
Name:NIELSON, ROBERT A (MS, MFT)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:NIELSON
Suffix:
Gender:M
Credentials:MS, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4270 W 5625 N
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:UT
Mailing Address - Zip Code:84066-4824
Mailing Address - Country:US
Mailing Address - Phone:435-353-4498
Mailing Address - Fax:435-353-4898
Practice Address - Street 1:4270 W 5625 N
Practice Address - Street 2:
Practice Address - City:ROOSEVELT
Practice Address - State:UT
Practice Address - Zip Code:84066-4824
Practice Address - Country:US
Practice Address - Phone:435-353-4498
Practice Address - Fax:435-353-4898
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT278057-3902106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist