Healthcare Provider Details

I. General information

NPI: 1831627470
Provider Name (Legal Business Name): CARLY KAEL NIELSEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2017
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4646 S 3500 W STE 2
WEST HAVEN UT
84401-9405
US

IV. Provider business mailing address

4646 S 3500 W STE 2
WEST HAVEN UT
84401-9405
US

V. Phone/Fax

Practice location:
  • Phone: 801-719-9410
  • Fax:
Mailing address:
  • Phone: 801-719-9410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number10816135-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number10816135-3503
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: