MEDICARE: LAUREL MALLONEE

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	8324665-3501	UT

General Provider Information

NPI Number	:	1871053553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAUREL MALLONEE

Provider Business Mailing Address
First Line	:	943 CHAPEL DR APT 2
Second Line	:
City	:	BOUNTIFUL
State	:	UT
Zip	:	84010-5935
Country	:	US
Telephone Number	:	801-230-4112
Fax Number	:

Provider Business Practice Location Address
First Line	:	925 E EXECUTIVE PARK DR STE B
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84117-3545
Country	:	US
Telephone Number	:	801-590-9277
Fax Number	:

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

Provider Enumeration Date	:	03/20/2019
Last Update Date	:	03/20/2019

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Directions to “ LAUREL MALLONEE ” Practice Location

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