MEDICARE: ASHLEY BROOKE SUTHERLAND 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	6985612-3501	UT

General Provider Information

NPI Number	:	1831416130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY BROOKE SUTHERLAND LCSW

Provider Business Mailing Address
First Line	:	925 E 900 S
Second Line	:	#42
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-1401
Country	:	US
Telephone Number	:	502-741-6065
Fax Number	:

Provider Business Practice Location Address
First Line	:	925 E 900 S
Second Line	:	#42
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-1401
Country	:	US
Telephone Number	:	502-741-6065
Fax Number	:	801-363-6564

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

Provider Enumeration Date	:	04/26/2010
Last Update Date	:	09/09/2011

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