MEDICARE: MS. AGNES ROBL

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	171M00000X	Case Manager/Care Coordinator	6697115-3503	UT
2	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1295022432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. AGNES ROBL

Provider Business Mailing Address
First Line	:	447 W BEARCAT DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-2519
Country	:	US
Telephone Number	:	801-355-2846
Fax Number	:

Provider Business Practice Location Address
First Line	:	447 W BEARCAT DR
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-2519
Country	:	US
Telephone Number	:	801-355-2846
Fax Number	:

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

Provider Enumeration Date	:	07/08/2011
Last Update Date	:	12/29/2014

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Directions to “ MS. AGNES ROBL ” Practice Location

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