Provider Demographics
NPI:1144853615
Name:WOOLSTENHULME, GLADE
Entity type:Individual
Prefix:
First Name:GLADE
Middle Name:
Last Name:WOOLSTENHULME
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 E SEGO LILY DR APT 302
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84070-4269
Mailing Address - Country:US
Mailing Address - Phone:612-875-0949
Mailing Address - Fax:
Practice Address - Street 1:11762 S STATE ST STE 160
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-7158
Practice Address - Country:US
Practice Address - Phone:801-654-3229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-12
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10787146-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical