MEDICARE: MR. JOSEPH HENRY TABISH 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	139727-3501	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	5286974304001	OTHER	UT	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1295903037
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOSEPH HENRY TABISH L.C.S.W.

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	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/14/2008
Last Update Date	:	09/24/2012

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