Healthcare Provider Details

I. General information

NPI: 1740121441
Provider Name (Legal Business Name): SCOTT WILTBANK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2026
Last Update Date: 04/06/2026
Certification Date: 04/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 E FORT UNION BLVD STE C118
MIDVALE UT
84047-5512
US

IV. Provider business mailing address

1039 W 40 S
OREM UT
84058-5265
US

V. Phone/Fax

Practice location:
  • Phone: 801-654-0772
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: