MEDICARE: SARAH CLISSOLD NELSON

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

General Provider Information

NPI Number	:	1104107069
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARAH CLISSOLD NELSON

Provider Business Mailing Address
First Line	:	699 E SOUTH TEMPLE STE 100B
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1159
Country	:	US
Telephone Number	:	385-202-0443
Fax Number	:

Provider Business Practice Location Address
First Line	:	699 E SOUTH TEMPLE STE 100B
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1159
Country	:	US
Telephone Number	:	385-202-0443
Fax Number	:

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

Provider Enumeration Date	:	09/06/2011
Last Update Date	:	01/26/2023

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Directions to “ SARAH CLISSOLD NELSON ” Practice Location

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