Provider Demographics
NPI:1699231142
Name:KIESEWETTER, DEBORAH MICHELLE
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:MICHELLE
Last Name:KIESEWETTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8306 S WATER OAK DR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84081-1829
Mailing Address - Country:US
Mailing Address - Phone:801-903-7990
Mailing Address - Fax:
Practice Address - Street 1:344 E 100 S STE 301
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84111-1727
Practice Address - Country:US
Practice Address - Phone:801-428-4257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 171M00000X
UT9681554-35021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator