Provider Demographics
NPI:1962640987
Name:PATRICK, NICHOLE (LCMHC)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:
Last Name:PATRICK
Suffix:
Gender:F
Credentials:LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9041 S LIBERTY BEND DR
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-4083
Mailing Address - Country:US
Mailing Address - Phone:971-329-9717
Mailing Address - Fax:
Practice Address - Street 1:13222 TREE SPARROW DR STE R210
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-2889
Practice Address - Country:US
Practice Address - Phone:801-872-5516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-29
Last Update Date:2025-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13232106-6004101YM0800X
WYLPC-1440101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1962640987Medicaid