Healthcare Provider Details

I. General information

NPI: 1821076803
Provider Name (Legal Business Name): DAVID COOP KOLDEWYN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/09/2006
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

1802 OMNI AVE
SALT LAKE CITY UT
84116-4600
US

V. Phone/Fax

Practice location:
  • Phone: 801-565-6900
  • Fax:
Mailing address:
  • Phone: 801-322-3136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2948753501
License Number StateUT

VII. Legacy identifiers

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

# 1
Identifier311135
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerDESERET MUTUAL
# 2
Identifier942938348K01
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerEDUCATORS MUTUAL
# 3
Identifier107001586101
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerINTERMOUNTAIN HEALTH CARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: