MEDICARE: HEATHER JOY CHASE LSAC

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	7101574-6006	UT

General Provider Information

NPI Number	:	1437427630
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER JOY CHASE LSAC

Provider Business Mailing Address
First Line	:	1450 SOUTH WEST TEMPLE
Second Line	:	APT F 304
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-5386
Country	:	US
Telephone Number	:	801-577-8842
Fax Number	:

Provider Business Practice Location Address
First Line	:	974 E SOUTH TEMPLE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1413
Country	:	US
Telephone Number	:	801-533-0070
Fax Number	:

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

Provider Enumeration Date	:	12/02/2011
Last Update Date	:	12/02/2011

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