MEDICARE: MATT MCDERMOTT

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	13204315-3502	UT

General Provider Information

NPI Number	:	1417775966
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATT MCDERMOTT

Provider Business Mailing Address
First Line	:	2588 W 2365 S
Second Line	:
City	:	WEST VALLEY
State	:	UT
Zip	:	84119-1249
Country	:	US
Telephone Number	:	801-975-7720
Fax Number	:	801-975-7720

Provider Business Practice Location Address
First Line	:	2588 W 2365 S
Second Line	:
City	:	WEST VALLEY
State	:	UT
Zip	:	84119-1249
Country	:	US
Telephone Number	:	801-975-7720
Fax Number	:	801-975-7720

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

Provider Enumeration Date	:	10/02/2024
Last Update Date	:	10/02/2024

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Directions to “ MATT MCDERMOTT ” Practice Location

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