MEDICARE: SALT LAKE MARITAL & FAMILY THERAPY CLINIC

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	8319884-3501	UT

General Provider Information

NPI Number	:	1578967642
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALT LAKE MARITAL & FAMILY THERAPY CLINIC

Provider Business Mailing Address
First Line	:	420 E SOUTH TEMPLE
Second Line	:	SUITE 300
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1319
Country	:	US
Telephone Number	:	801-521-5068
Fax Number	:	801-521-7021

Provider Business Practice Location Address
First Line	:	420 E SOUTH TEMPLE
Second Line	:	SUITE 300
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1319
Country	:	US
Telephone Number	:	801-521-5068
Fax Number	:	801-521-7021

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MS. MARGARET THOMPSON
Credential	:	LCSW
Telephone Number	:	801-521-5068

Provider Enumeration Date	:	10/17/2014
Last Update Date	:	10/17/2014

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