MEDICARE: CARLY KAEL NIELSEN

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	106S00000X	Behavior Technician
2	171M00000X	Case Manager/Care Coordinator	10816135-3503	UT
3	1041C0700X	Clinical Social Worker	10816135-3501	UT

General Provider Information

NPI Number	:	1831627470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY KAEL NIELSEN

Provider Business Mailing Address
First Line	:	4646 S 3500 W STE 2
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-9405
Country	:	US
Telephone Number	:	801-719-9410
Fax Number	:

Provider Business Practice Location Address
First Line	:	4646 S 3500 W STE 2
Second Line	:
City	:	WEST HAVEN
State	:	UT
Zip	:	84401-9405
Country	:	US
Telephone Number	:	801-719-9410
Fax Number	:

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

Provider Enumeration Date	:	05/26/2017
Last Update Date	:	01/20/2025

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