Healthcare Provider Details

I. General information

NPI: 1104131697
Provider Name (Legal Business Name): NIKKI SCHWISOW MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE MANSON MSW, LCSW

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 02/02/2024
Certification Date: 07/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8537 S REDWOOD RD STE C
WEST JORDAN UT
84088-5713
US

IV. Provider business mailing address

8537 S REDWOOD RD STE C
WEST JORDAN UT
84088-5713
US

V. Phone/Fax

Practice location:
  • Phone: 385-449-2200
  • Fax:
Mailing address:
  • Phone: 385-449-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8034933-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number105617
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904014439
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberI.2103013
License Number StateOH
# 5
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: