MEDICARE: LEE LEGRAND PERRY 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	104100000X	Social Worker	59746953502	UT
2	1041C0700X	Clinical Social Worker	5974695-3501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1760588818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEE LEGRAND PERRY LCSW

Provider Business Mailing Address
First Line	:	5149 S 1500 W STE 180
Second Line	:
City	:	RIVERDALE
State	:	UT
Zip	:	84405-3926
Country	:	US
Telephone Number	:	801-475-0402
Fax Number	:	801-475-7464

Provider Business Practice Location Address
First Line	:	5149 S 1500 W
Second Line	:
City	:	RIVERDALE
State	:	UT
Zip	:	84405-3926
Country	:	US
Telephone Number	:	801-475-0402
Fax Number	:	801-475-7464

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

Provider Enumeration Date	:	09/16/2006
Last Update Date	:	06/18/2019

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