MEDICARE: INNER TRADITIONS COUNSELING SERVICES

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

General Provider Information

NPI Number	:	1194895136
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INNER TRADITIONS COUNSELING SERVICES

Provider Business Mailing Address
First Line	:	807 E SOUTH TEMPLE STE 370
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1351
Country	:	US
Telephone Number	:	801-467-2072
Fax Number	:	801-363-0074

Provider Business Practice Location Address
First Line	:	807 E SOUTH TEMPLE STE 370
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1351
Country	:	US
Telephone Number	:	801-467-2072
Fax Number	:	801-363-0074

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. CATHY MARTINEZ
Credential	:	LCSW
Telephone Number	:	801-467-2072

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	06/23/2008

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