Healthcare Provider Details

I. General information

NPI: 1841857315
Provider Name (Legal Business Name): STEVEN NIEL NICKOLAISEN PHD, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 05/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 E 3300 S
SALT LAKE CITY UT
84106-2522
US

IV. Provider business mailing address

606 S 1100 E
SALT LAKE CITY UT
84102-3902
US

V. Phone/Fax

Practice location:
  • Phone: 801-483-1600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number8152100-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: