MEDICARE: HAREF MONTALVO 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	1041C0700X	Clinical Social Worker	75202803502	UT

General Provider Information

NPI Number	:	1215251327
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAREF MONTALVO CSW

Provider Business Mailing Address
First Line	:	5333 S 2150 W
Second Line	:
City	:	TAYLORSVILLE
State	:	UT
Zip	:	84118-1360
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1760 W 4805 S
Second Line	:
City	:	TAYLORSVILLE
State	:	UT
Zip	:	84118-1177
Country	:	US
Telephone Number	:	801-955-9110
Fax Number	:

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

Provider Enumeration Date	:	03/17/2010
Last Update Date	:	03/17/2010

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