MEDICARE: MS. ROXANA CORDOVA

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	10413363-3502	UT

General Provider Information

NPI Number	:	1528527090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ROXANA CORDOVA

Provider Business Mailing Address
First Line	:	1111 E BRICKYARD RD STE 218
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84106-2588
Country	:	US
Telephone Number	:	801-746-4334
Fax Number	:	801-746-4337

Provider Business Practice Location Address
First Line	:	1111 E BRICKYARD RD STE 218
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2588
Country	:	US
Telephone Number	:	801-746-4334
Fax Number	:

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

Provider Enumeration Date	:	03/14/2019
Last Update Date	:	03/14/2019

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