Provider Demographics
NPI:1669733481
Name:NIELSEN, MICHELLE ANTOINETTE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ANTOINETTE
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ANTOINETTE
Other - Last Name:LIZON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1760 WEST 4805 SOUTH
Mailing Address - Street 2:
Mailing Address - City:TAYLORSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84123
Mailing Address - Country:US
Mailing Address - Phone:801-955-9110
Mailing Address - Fax:801-955-9411
Practice Address - Street 1:1760 WEST 4805 SOUTH
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:UT
Practice Address - Zip Code:84123
Practice Address - Country:US
Practice Address - Phone:801-955-9110
Practice Address - Fax:801-955-9411
Is Sole Proprietor?:No
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8266980-3502104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker