Healthcare Provider Details

I. General information

NPI: 1821199472
Provider Name (Legal Business Name): ELIJAH KIMBALL NIELSON CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 N FREEDOM BLVD
PROVO UT
84601-1677
US

IV. Provider business mailing address

500 FOOTHILL BLVD
SALT LAKE CITY UT
84148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-373-4760
  • Fax:
Mailing address:
  • Phone: 801-582-1565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number5687052-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: