Provider Demographics
NPI:1295473916
Name:BLACK, NATHAN (CSW)
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:M
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5383 S 900 E STE 103
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7266
Mailing Address - Country:US
Mailing Address - Phone:801-872-5516
Mailing Address - Fax:801-212-9942
Practice Address - Street 1:3051 W MAPLE LOOP DR STE 210
Practice Address - Street 2:
Practice Address - City:LEHI
Practice Address - State:UT
Practice Address - Zip Code:84043-4602
Practice Address - Country:US
Practice Address - Phone:801-872-5516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-23
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12256132-35061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT11778360-3502OtherLICENSE