MEDICARE: NICOLE MANON FENWICK 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	50039293501	UT

General Provider Information

NPI Number	:	1235457094
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MANON FENWICK LCSW

Provider Business Mailing Address
First Line	:	1111 BRICKYARD RD
Second Line	:	SUITE #109
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2560
Country	:	US
Telephone Number	:	801-746-4334
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 BRICKYARD RD
Second Line	:	SUITE #109
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-2560
Country	:	US
Telephone Number	:	801-746-4334
Fax Number	:

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

Provider Enumeration Date	:	05/04/2010
Last Update Date	:	12/27/2021

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