Healthcare Provider Details

I. General information

NPI: 1578107678
Provider Name (Legal Business Name): SETH CONRAD CHIPMAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 E 600 S
PROVO UT
84606-4854
US

IV. Provider business mailing address

750 N FREEDOM BLVD
PROVO UT
84601-1677
US

V. Phone/Fax

Practice location:
  • Phone: 801-852-1624
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11343983-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: