Healthcare Provider Details

I. General information

NPI: 1184694077
Provider Name (Legal Business Name): REGGIE D WILSON LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 W 7200 S
MIDVALE UT
84047-3703
US

IV. Provider business mailing address

1180 BIG PINE DR
SANDY UT
84094-7222
US

V. Phone/Fax

Practice location:
  • Phone: 801-565-6900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number3335063501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier887452
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerDESERET MUTUAL
# 2
Identifier107032323101
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerINTERMOUNTAIN HEALTH CARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: