MEDICARE: CHERYL KELSTROM-SMITH LCSW, LLC

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	4730671-3501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12/19/1949	OTHER	UT	BIRTHDAY
2	SKYLER	OTHER	UT	DOG

General Provider Information

NPI Number	:	1417235284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHERYL KELSTROM-SMITH LCSW, LLC

Provider Business Mailing Address
First Line	:	PO BOX 213
Second Line	:
City	:	ROY
State	:	UT
Zip	:	84067-0213
Country	:	US
Telephone Number	:	801-475-0402
Fax Number	:	801-475-7464

Provider Business Practice Location Address
First Line	:	5149 S 1500 W
Second Line	:
City	:	RIVERDALE
State	:	UT
Zip	:	84405-3926
Country	:	US
Telephone Number	:	801-475-0402
Fax Number	:	801-475-7464

Authorized Official
Title or Position	:	PROVIDER/OWNER
Name	:	MS. CHERYL KELSTROM-SMITH
Credential	:	LCSW
Telephone Number	:	801-475-0402

Provider Enumeration Date	:	07/28/2011
Last Update Date	:	08/12/2011

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