MEDICARE: ISABEL MEDELLIN

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1124326889
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ISABEL MEDELLIN

Provider Business Mailing Address
First Line	:	4621 CAPE RIDGE LN
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84128-5626
Country	:	US
Telephone Number	:	801-706-0887
Fax Number	:

Provider Business Practice Location Address
First Line	:	4621 CAPE RIDGE LN
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84128-5626
Country	:	US
Telephone Number	:	801-706-0887
Fax Number	:

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

Provider Enumeration Date	:	03/04/2011
Last Update Date	:	03/04/2011

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