Healthcare Provider Details

I. General information

NPI: 1912156431
Provider Name (Legal Business Name): KATHY WICKERSHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHY HOLTHUS

II. Dates (important events)

Enumeration Date: 09/09/2008
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1398 E LUCK LN
MILLCREEK UT
84106-2944
US

IV. Provider business mailing address

1877 S WYOMING ST
SALT LAKE CITY UT
84108-3235
US

V. Phone/Fax

Practice location:
  • Phone: 801-251-6767
  • Fax:
Mailing address:
  • Phone: 801-712-1441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10570331-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: