Healthcare Provider Details

I. General information

NPI: 1861165839
Provider Name (Legal Business Name): SUSAN KELLY NIEBAUM PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 02/03/2022
Certification Date: 02/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

408 E KELSEY VIEW LN
SOUTH SALT LAKE UT
84115-4979
US

IV. Provider business mailing address

408 E KELSEY VIEW LN
SOUTH SALT LAKE UT
84115-4979
US

V. Phone/Fax

Practice location:
  • Phone: 406-212-2177
  • Fax:
Mailing address:
  • Phone: 406-212-2177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12585557-4405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163WP0807X
TaxonomyChild & Adolescent Psychiatric/Mental Health Registered Nurse
License Number16869
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: