MEDICARE: ALZHEIMERS DISEASE AND RELATED DISORDERS ASSOCIATION UTAH CHAPTER

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	103TP2701X	Group Psychotherapy Psychologist	0008208	UT

General Provider Information

NPI Number	:	1235417684
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ALZHEIMERS DISEASE AND RELATED DISORDERS ASSOCIATION UTAH CHAPTER

Provider Business Mailing Address
First Line	:	855 E 4800 S STE 100
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-5513
Country	:	US
Telephone Number	:	801-265-1944
Fax Number	:

Provider Business Practice Location Address
First Line	:	855 E 4800 S STE 100
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84107-5513
Country	:	US
Telephone Number	:	801-265-1944
Fax Number	:

Authorized Official
Title or Position	:	PROGRAM MANAGER
Name	:	SYLVIA BRUNISHOLZ
Credential	:	LCSW
Telephone Number	:	801-347-0074

Provider Enumeration Date	:	08/02/2011
Last Update Date	:	12/06/2012

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