MEDICARE: SEQUOIA COUNSELING SERVICES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	134757	UT
2	1041C0700X	Clinical Social Worker	13457	UT
3	1041C0700X	Clinical Social Worker	18922	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	005569802	OTHER	UT	MEDICARE A

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	52836974304001	OTHER	UT	BLUE CROSS BLUE SHEILD

General Provider Information

NPI Number	:	1053583435
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SEQUOIA COUNSELING SERVICES

Provider Business Mailing Address
First Line	:	3378 SOUTH 900 EAST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2070
Country	:	US
Telephone Number	:	801-463-7520
Fax Number	:	801-463-7525

Provider Business Practice Location Address
First Line	:	3378 SOUTH 900 EAST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2070
Country	:	US
Telephone Number	:	801-463-7520
Fax Number	:	801-463-7525

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	MR. JOSEPH HENRY TABISH
Credential	:	L.C.S.W.
Telephone Number	:	801-463-7520

Provider Enumeration Date	:	03/26/2008
Last Update Date	:	09/24/2012

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1790064145 — JESSICA E KATZ MS, LMHC, LCMHC, LPC
Practice Location Address:

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