MEDICARE: MS. CLAIR MELLENTHIN 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	101YM0800X	Mental Health Counselor	5228904-3501	UT

General Provider Information

NPI Number	:	1336275478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CLAIR MELLENTHIN LCSW

Provider Business Mailing Address
First Line	:	1308 S 1700 E STE 210
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2273
Country	:	US
Telephone Number	:	801-949-4524
Fax Number	:	801-355-9614

Provider Business Practice Location Address
First Line	:	1308 S 1700 E STE 210
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84108-2273
Country	:	US
Telephone Number	:	801-949-4524
Fax Number	:	801-355-9614

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

Provider Enumeration Date	:	02/25/2007
Last Update Date	:	07/08/2007

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