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NPI Code Detail

MEDICARE: NICOLE M GOTBERG SSW

MEDICARE: NICOLE M GOTBERG SSW
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
1253J00000XFoster Care Agency
2104100000XSocial Worker9450078-3503UT

General Provider Information

NPI Number : 1407288145
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICOLE M GOTBERG SSW
Provider Business Mailing Address
First Line : 195 N 1950 W
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84116-3100
Country : US
Telephone Number : 385-315-3237
Fax Number :
Provider Business Practice Location Address
First Line : 195 N 1950 W
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84116-3100
Country : US
Telephone Number : 801-538-4001
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 08/05/2013
Last Update Date : 09/22/2015

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Directions to “ NICOLE M GOTBERG SSW” Practice Location

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