MEDICARE: PEGGY DE AZEVEDO

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	140103-3501	UT

General Provider Information

NPI Number	:	1154401867
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PEGGY DE AZEVEDO

Provider Business Mailing Address
First Line	:	1327 EAST SOUTH TEMPLE
Second Line	:	#14
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4885 S 900 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5746
Country	:	US
Telephone Number	:	801-240-6500
Fax Number	:

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

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	07/08/2007

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