MEDICARE: MARY JUNE LATU 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	7114496-3501	UT

General Provider Information

NPI Number	:	1881838290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JUNE LATU LCSW

Provider Business Mailing Address
First Line	:	246 HILLSIDE CIR
Second Line	:
City	:	ALPINE
State	:	UT
Zip	:	84004-1342
Country	:	US
Telephone Number	:	315-408-7775
Fax Number	:

Provider Business Practice Location Address
First Line	:	1141 E 3900 S
Second Line	:	SUITE A170
City	:	SLC
State	:	UT
Zip	:	84124-1215
Country	:	US
Telephone Number	:	801-284-4990
Fax Number	:

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

Provider Enumeration Date	:	04/29/2009
Last Update Date	:	10/14/2010

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