MEDICARE: MS. SUZANNE MARIE FIELDS L.C.S.W.

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	3609673501	UT

General Provider Information

NPI Number	:	1093790552
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUZANNE MARIE FIELDS L.C.S.W.

Provider Business Mailing Address
First Line	:	1758 S 800 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3102
Country	:	US
Telephone Number	:	801-808-0244
Fax Number	:	801-278-0489

Provider Business Practice Location Address
First Line	:	2040 MURRAY HOLLADAY RD
Second Line	:	SUITE 222
City	:	HOLLADAY
State	:	UT
Zip	:	84117-5185
Country	:	US
Telephone Number	:	801-808-0244
Fax Number	:	801-278-0489

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

Provider Enumeration Date	:	12/07/2005
Last Update Date	:	05/07/2012

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