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NPI Code Detail

MEDICARE: PROF. BARRETT BONELLA LCSW

MEDICARE: PROF. BARRETT BONELLA 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
11041C0700XClinical Social Worker6234378-3501UT

General Provider Information

NPI Number : 1124111836
Entity Type Code : Individual
Provider Name (Legal Business Name) : PROF. BARRETT BONELLA LCSW
Provider Business Mailing Address
First Line : 2284 S GREEN ST
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84106-1410
Country : US
Telephone Number : 801-467-6060
Fax Number :
Provider Business Practice Location Address
First Line : 1588 MAJOR ST
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84115-1631
Country : US
Telephone Number : 801-467-6060
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/02/2006
Last Update Date : 06/23/2010

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