Provider Demographics
NPI:1265733414
Name:CAMPOLUCCI, NICOLE (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CAMPOLUCCI
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 1:4460 S HIGHLAND DR STE 210
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124-3550
Mailing Address - Country:US
Mailing Address - Phone:888-949-4864
Mailing Address - Fax:
Practice Address - Street 1:450 S 900 E
Practice Address - Street 2:SUITE 300
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2981
Practice Address - Country:US
Practice Address - Phone:801-534-7912
Practice Address - Fax:801-532-3608
Is Sole Proprietor?:No
Enumeration Date:2010-11-04
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT364989-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical