Healthcare Provider Details

I. General information

NPI: 1164354924
Provider Name (Legal Business Name): BLAIR NICOL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4007 S 1500 W
VERNAL UT
84078-4665
US

IV. Provider business mailing address

4263 W TWILIGHT DR
SALT LAKE CITY UT
84118-4623
US

V. Phone/Fax

Practice location:
  • Phone: 628-222-9621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number13020916-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: