=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760298640
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATHEW EDVIK CSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2024
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9263 S REDWOOD RD BLDG 8
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84088-6571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-566-0749
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3030 W GREAT PASTURE RD
-----------------------------------------------------
City | WEST JORDAN
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84088-5339
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-831-0234
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6671459-3502
-----------------------------------------------------
License Number State | UT
-----------------------------------------------------