| NPI | 1134616899 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | MICHAEL WICKERSHAM Provider/Owner 801-712-1790 |
| Organization Subpart ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: UT 94280933501) |
| Enumeration Date | 2018-04-18 |
| Last Update Date | 2018-04-18 |