MEDICARE: ELLIOTT DONALDSON LCSW

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	10070159-3501	UT

General Provider Information

NPI Number	:	1205290921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELLIOTT DONALDSON LCSW

Provider Business Mailing Address
First Line	:	150 S 600 E STE 6C
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1884
Country	:	US
Telephone Number	:	385-390-2680
Fax Number	:

Provider Business Practice Location Address
First Line	:	150 S 600 E STE 6C
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1884
Country	:	US
Telephone Number	:	385-390-2680
Fax Number	:

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

Provider Enumeration Date	:	04/08/2016
Last Update Date	:	12/05/2023

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