MEDICARE: MILLCREEK THERAPY PSYCHOLOGICAL SERVICES

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

General Provider Information

NPI Number	:	1033811401
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MILLCREEK THERAPY PSYCHOLOGICAL SERVICES

Provider Business Mailing Address
First Line	:	1398 E LUCK LN
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84106-2944
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1398 E LUCK LN
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84106-2944
Country	:	US
Telephone Number	:	801-870-3716
Fax Number	:

Authorized Official
Title or Position	:	OWNER / LCSW
Name	:	NANCY KIMMERLY
Credential	:	LCSW
Telephone Number	:	801-870-3716

Provider Enumeration Date	:	03/20/2023
Last Update Date	:	10/17/2023

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