Provider Demographics
NPI:1104144203
Name:DAHLGREN, NICOLE (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:DAHLGREN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4135 W 5600 N
Mailing Address - Street 2:
Mailing Address - City:BRIGHAM CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84302-3512
Mailing Address - Country:US
Mailing Address - Phone:435-770-1063
Mailing Address - Fax:
Practice Address - Street 1:11620 S STATE ST STE 1404
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7124
Practice Address - Country:US
Practice Address - Phone:801-867-4488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-13
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7510233-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT260022408OtherRAILROAD MEDICARE
UT876000308007Medicaid
UT000055266Medicare PIN