Healthcare Provider Details

I. General information

NPI: 1437652773
Provider Name (Legal Business Name): ALEXANDRIA MICKELSEN THOMAS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ALEXANDRIA MICKELSEN LCSW

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 02/21/2023
Certification Date: 02/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14241 S REDWOOD RD STE 300
BLUFFDALE UT
84065-5223
US

IV. Provider business mailing address

1305 E SHALLOW WATER RD
EAGLE MOUNTAIN UT
84005-6060
US

V. Phone/Fax

Practice location:
  • Phone: 385-342-2808
  • Fax:
Mailing address:
  • Phone: 801-717-6391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11313193-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: