MEDICARE: MS. ANGELA MARIE FANJUL 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	5586510-3502	UT

General Provider Information

NPI Number	:	1699870220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANGELA MARIE FANJUL LCSW

Provider Business Mailing Address
First Line	:	621 SENATE CIR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84104-2458
Country	:	US
Telephone Number	:	801-971-9377
Fax Number	:

Provider Business Practice Location Address
First Line	:	860 E 4500 S STE 204
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-3014
Country	:	US
Telephone Number	:	801-261-3440
Fax Number	:

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

Provider Enumeration Date	:	09/14/2006
Last Update Date	:	07/08/2007

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