Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker |
NPI | 1003249418 |
---|---|
Provider Name | Matthew Kael Nisson |
First Address | Salt Lake City, UT 84121-1720 |
Second Address | Salt Lake City, UT 84121-1720 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/08/2013 |
Last Update Date | 27/02/2017 |