Healthcare Provider Details

I. General information

NPI: 1619379971
Provider Name (Legal Business Name): SELMA HERCINOVIC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 MEDICAL DR
BOUNTIFUL UT
84010-4908
US

IV. Provider business mailing address

110 S 800 E 406
SALT LAKE CITY UT
84102-4118
US

V. Phone/Fax

Practice location:
  • Phone: 801-299-3780
  • Fax:
Mailing address:
  • Phone: 801-598-1096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851568-3501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: