MEDICARE: TYLER TEST SOCIAL WORKER

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	13996439-3502	UT

General Provider Information

NPI Number	:	1710795117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TYLER TEST SOCIAL WORKER

Provider Business Mailing Address
First Line	:	1090 E VIEW POINT DR APT F208
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84094-0780
Country	:	US
Telephone Number	:	940-231-8138
Fax Number	:

Provider Business Practice Location Address
First Line	:	5620 S WATERBURY WAY
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1180
Country	:	US
Telephone Number	:	303-514-2605
Fax Number	:

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

Provider Enumeration Date	:	12/18/2024
Last Update Date	:	12/18/2024

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Directions to “ TYLER TEST SOCIAL WORKER” Practice Location

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