MEDICARE: MS. MOLLY GEORGE PRINCE 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	333285-3501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	03332853501001	OTHER	UT	BCBS

General Provider Information

NPI Number	:	1396700548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MOLLY GEORGE PRINCE LCSW

Provider Business Mailing Address
First Line	:	PO BOX 179
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84110-0179
Country	:	US
Telephone Number	:	801-680-4705
Fax Number	:	801-906-0129

Provider Business Practice Location Address
First Line	:	3098 S HIGHLAND DR
Second Line	:	SUITE 202
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3085
Country	:	US
Telephone Number	:	801-680-4705
Fax Number	:	801-906-0129

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

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	03/04/2013

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