Healthcare Provider Details

I. General information

NPI: 1619294410
Provider Name (Legal Business Name): KIMALEE ANN URBOM CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 05/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3944 S 400 E
SALT LAKE CITY UT
84107-1600
US

IV. Provider business mailing address

3944 S 400 E
SALT LAKE CITY UT
84107-1600
US

V. Phone/Fax

Practice location:
  • Phone: 801-261-1442
  • Fax:
Mailing address:
  • Phone: 801-261-1442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number49840923502
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: