Provider Demographics
NPI:1740335850
Name:KELSTROM-SMITH, CHERYL (LCSW)
Entity type:Individual
Prefix:MRS
First Name:CHERYL
Middle Name:
Last Name:KELSTROM-SMITH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:CHERYL
Other - Middle Name:
Other - Last Name:KELSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:5522 S 3100 W
Mailing Address - Street 2:
Mailing Address - City:ROY
Mailing Address - State:UT
Mailing Address - Zip Code:84067-9456
Mailing Address - Country:US
Mailing Address - Phone:801-710-9986
Mailing Address - Fax:385-393-8624
Practice Address - Street 1:5522 S 3100 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-9456
Practice Address - Country:US
Practice Address - Phone:801-710-9986
Practice Address - Fax:385-393-8624
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-25
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT47306713501101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT005760001Medicare ID - Type Unspecified