MEDICARE: KIMBERLY NELSON PARK CSW

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	104100000X	Social Worker	7290402-3502	UT

General Provider Information

NPI Number	:	1023243854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY NELSON PARK CSW

Provider Business Mailing Address
First Line	:	1155 E 2100 S
Second Line	:	APT 728
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2872
Country	:	US
Telephone Number	:	801-510-3966
Fax Number	:

Provider Business Practice Location Address
First Line	:	1760 W 4805 S
Second Line	:
City	:	TAYLORSVILLE
State	:	UT
Zip	:	84118-1177
Country	:	US
Telephone Number	:	801-955-9110
Fax Number	:

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

Provider Enumeration Date	:	05/22/2009
Last Update Date	:	05/22/2009

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