MEDICARE: ANNA CONNOLLY CSW

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	11351677-3502	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NA	OTHER		NA

General Provider Information

NPI Number	:	1174170344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNA CONNOLLY CSW

Provider Business Mailing Address
First Line	:	2057 E ATKIN AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1901
Country	:	US
Telephone Number	:	801-856-4863
Fax Number	:

Provider Business Practice Location Address
First Line	:	2655 S LAKE ERIE DR
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-7350
Country	:	US
Telephone Number	:	801-856-4863
Fax Number	:

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

Provider Enumeration Date	:	08/22/2019
Last Update Date	:	08/22/2019

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