MEDICARE: MRS. JUSTYN HASKELL MANLEY JUSTYN MANLEY

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	104100000X	Social Worker	8262078-3502	UT
2	1041C0700X	Clinical Social Worker	8262078-3501	UT

General Provider Information

NPI Number	:	1528375607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JUSTYN HASKELL MANLEY JUSTYN MANLEY

Provider Business Mailing Address
First Line	:	8947 N PROMONTORY RIDGE DR
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84098-5786
Country	:	US
Telephone Number	:	435-640-1327
Fax Number	:

Provider Business Practice Location Address
First Line	:	1912 SIDEWINDER DR STE 201
Second Line	:
City	:	PARK CITY
State	:	UT
Zip	:	84060-7257
Country	:	US
Telephone Number	:	435-640-1327
Fax Number	:

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

Provider Enumeration Date	:	09/09/2010
Last Update Date	:	06/28/2019

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