MEDICARE: MR. NICHOLAS KONSTANTINE TSANDES LCSW

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	1041C0700X	Clinical Social Worker	373374-3501	UT

General Provider Information

NPI Number	:	1124076625
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NICHOLAS KONSTANTINE TSANDES LCSW

Provider Business Mailing Address
First Line	:	1814 FIELDCREST LN
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5941
Country	:	US
Telephone Number	:	801-274-2794
Fax Number	:

Provider Business Practice Location Address
First Line	:	2040 MURRAY HOLLADAY RD
Second Line	:	SUITE 117
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5185
Country	:	US
Telephone Number	:	801-913-1497
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	07/08/2007

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