Provider Demographics
NPI:1972714038
Name:CHIDESTER, ROBERT (LCSW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:CHIDESTER
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 1:3670 QUINCY AVE
Mailing Address - Street 2:STE 103
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-1977
Mailing Address - Country:US
Mailing Address - Phone:801-621-5666
Mailing Address - Fax:801-621-1322
Practice Address - Street 1:3670 QUINCY AVE
Practice Address - Street 2:STE 103
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-1977
Practice Address - Country:US
Practice Address - Phone:801-621-5666
Practice Address - Fax:801-621-1322
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT276026-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical