MEDICARE: WENDY EVANOFF

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	:	1144597303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDY EVANOFF

Provider Business Mailing Address
First Line	:	974 E SOUTH TEMPLE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1413
Country	:	US
Telephone Number	:	801-533-0070
Fax Number	:	801-596-2240

Provider Business Practice Location Address
First Line	:	974 E SOUTH TEMPLE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1413
Country	:	US
Telephone Number	:	801-533-0070
Fax Number	:	801-596-2240

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

Provider Enumeration Date	:	11/16/2011
Last Update Date	:	11/16/2011

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