Healthcare Provider Details

I. General information

NPI: 1801875778
Provider Name (Legal Business Name): JAMES D WETZEL LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
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

495 TONALEA DR
MURRAY UT
84107-6231
US

V. Phone/Fax

Practice location:
  • Phone: 801-565-6900
  • Fax: 801-569-0899
Mailing address:
  • Phone: 801-293-7073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number221197743501
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier11977435000001
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerBLUE CROSS
# 2
Identifier107011001101
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerINTRMTN. HEALTH CARE
# 3
Identifier740396
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerDESERET MUTUAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: