MEDICARE: WILFORD KIMBALL DELAMARE LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1291363501	UT

General Provider Information

NPI Number	:	1376125484
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WILFORD KIMBALL DELAMARE LCSW

Provider Business Mailing Address
First Line	:	210 CLUB HOUSE CT
Second Line	:
City	:	NORTH SALT LAKE
State	:	UT
Zip	:	84054-3381
Country	:	US
Telephone Number	:	801-698-7704
Fax Number	:

Provider Business Practice Location Address
First Line	:	9289 S REDWOOD RD
Second Line	:
City	:	WEST JORDAN
State	:	UT
Zip	:	84088-6730
Country	:	US
Telephone Number	:	801-703-4830
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2021
Last Update Date	:	04/27/2021

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