MEDICARE: EDNA MERRY WILCOCK R.N., L.C.S.W.

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	2215843501	UT

General Provider Information

NPI Number	:	1194714766
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EDNA MERRY WILCOCK R.N., L.C.S.W.

Provider Business Mailing Address
First Line	:	363 WALL ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84103-1637
Country	:	US
Telephone Number	:	801-359-7648
Fax Number	:

Provider Business Practice Location Address
First Line	:	925 E 900 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-1401
Country	:	US
Telephone Number	:	801-541-5443
Fax Number	:

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

Provider Enumeration Date	:	10/17/2005
Last Update Date	:	07/08/2007

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