MEDICARE: MRS. NITA SUE GRAHAM LSW

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	6332320-3503	UT

General Provider Information

NPI Number	:	1154547750
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NITA SUE GRAHAM LSW

Provider Business Mailing Address
First Line	:	22 TIMBER LAKES EST
Second Line	:
City	:	HEBER CITY
State	:	UT
Zip	:	84032-9651
Country	:	US
Telephone Number	:	435-654-3003
Fax Number	:	435-654-0309

Provider Business Practice Location Address
First Line	:	55 S 500 E
Second Line	:
City	:	HEBER CITY
State	:	UT
Zip	:	84032-1918
Country	:	US
Telephone Number	:	435-654-3003
Fax Number	:	435-654-3090

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/08/2007

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