Provider Demographics
NPI:1861472177
Name:MITCHELL, KIMBERLY (LCSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MITCHELL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:NIELSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:14106 CANDY PULL DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-7513
Mailing Address - Country:US
Mailing Address - Phone:801-577-2712
Mailing Address - Fax:
Practice Address - Street 1:780 GUARDSMAN WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1374
Practice Address - Country:US
Practice Address - Phone:801-581-0194
Practice Address - Fax:801-581-0193
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT4912299-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT107035680101OtherINTERMTN. HEALTH CARE
UT907899OtherDESERET MUTUAL