Provider Demographics
NPI:1154984839
Name:NISENSON, ADAM
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:NISENSON
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 1:2521 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84106-1307
Mailing Address - Country:US
Mailing Address - Phone:713-256-8033
Mailing Address - Fax:
Practice Address - Street 1:4505 S WASATCH BLVD STE 290
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-4204
Practice Address - Country:US
Practice Address - Phone:385-695-5949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-17
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10312526-3904103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling