Provider Demographics
NPI:1912156431
Name:WICKERSHAM, KATHY
Entity type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:WICKERSHAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:HOLTHUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1877 S WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-3235
Mailing Address - Country:US
Mailing Address - Phone:801-712-1441
Mailing Address - Fax:
Practice Address - Street 1:1398 E LUCK LN
Practice Address - Street 2:
Practice Address - City:MILLCREEK
Practice Address - State:UT
Practice Address - Zip Code:84106-2944
Practice Address - Country:US
Practice Address - Phone:801-251-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-09
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10570331-6004101YM0800X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator