MEDICARE: MR. MICHAEL TED BOMAN 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	373112-3501	UT

General Provider Information

NPI Number	:	1508828930
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL TED BOMAN LCSW

Provider Business Mailing Address
First Line	:	3564 S 7200 W
Second Line	:
City	:	MAGNA
State	:	UT
Zip	:	84044-3507
Country	:	US
Telephone Number	:	801-250-2909
Fax Number	:	801-252-0444

Provider Business Practice Location Address
First Line	:	3564 S 7200 W
Second Line	:
City	:	MAGNA
State	:	UT
Zip	:	84044-3507
Country	:	US
Telephone Number	:	801-250-2909
Fax Number	:	801-252-0444

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

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	07/08/2007

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