Healthcare Provider Details

I. General information

NPI: 1386082733
Provider Name (Legal Business Name): CLINT O WOLFE CSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2013
Last Update Date: 06/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 E 8400 S
SANDY UT
84070-0525
US

IV. Provider business mailing address

140 W 100 N
SPRINGVILLE UT
84663-1303
US

V. Phone/Fax

Practice location:
  • Phone: 801-566-2556
  • Fax:
Mailing address:
  • Phone: 801-491-6079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7872309-3502
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number567142
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: