Provider Demographics
NPI:1922589100
Name:MILLIKAN, KIMBERLY BROOKE (CSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:BROOKE
Last Name:MILLIKAN
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84115-2724
Mailing Address - Country:US
Mailing Address - Phone:801-359-8862
Mailing Address - Fax:801-359-8510
Practice Address - Street 1:2200 S STATE ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84115-2724
Practice Address - Country:US
Practice Address - Phone:801-359-8862
Practice Address - Fax:801-359-8510
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105317433502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker