Provider Demographics
NPI:1154987295
Name:DANGERFIELD, NICHOLE PORRITT
Entity type:Individual
Prefix:MS
First Name:NICHOLE
Middle Name:PORRITT
Last Name:DANGERFIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NIKKI
Other - Middle Name:
Other - Last Name:DANGERFIELD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:515 S 700 E STE 2A
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-2855
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 S. 700 E.
Practice Address - Street 2:2A
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-2855
Practice Address - Country:US
Practice Address - Phone:801-895-4224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-14
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT106S00000XMedicaid