Provider Demographics
NPI:1780410324
Name:NILSSON, RENEA (LCSW)
Entity type:Individual
Prefix:
First Name:RENEA
Middle Name:
Last Name:NILSSON
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:PO BOX 111
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-0111
Mailing Address - Country:US
Mailing Address - Phone:435-709-6282
Mailing Address - Fax:
Practice Address - Street 1:150 N MAIN ST STE 204E
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-1671
Practice Address - Country:US
Practice Address - Phone:435-709-6282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-10
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.099245021041C0700X
UT14072833-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical