Provider Demographics
NPI:1831627470
Name:NIELSEN, CARLY KAEL
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:KAEL
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 S 3500 W STE 2
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:UT
Mailing Address - Zip Code:84401-9405
Mailing Address - Country:US
Mailing Address - Phone:801-719-9410
Mailing Address - Fax:
Practice Address - Street 1:4646 S 3500 W STE 2
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:UT
Practice Address - Zip Code:84401-9405
Practice Address - Country:US
Practice Address - Phone:801-719-9410
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-26
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
UT10816135-3503171M00000X
UT10816135-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty