Provider Demographics
NPI:1962076349
Name:KILLPACK, NIKKI C (LCSW)
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:C
Last Name:KILLPACK
Suffix:
Gender:
Credentials:LCSW
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:CALTON
Other - Last Name:KILLPACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CSW
Mailing Address - Street 1:780 S 2000 W STE A101
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:UT
Mailing Address - Zip Code:84075-9612
Mailing Address - Country:US
Mailing Address - Phone:801-609-5515
Mailing Address - Fax:
Practice Address - Street 1:780 S 2000 W STE A101
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:UT
Practice Address - Zip Code:84075-9612
Practice Address - Country:US
Practice Address - Phone:801-609-5515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-19
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
UT13427461-3502104100000X
UT13427461-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker