MEDICARE: EMMA SULLIVAN

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	104100000X	Social Worker
2	1041C0700X	Clinical Social Worker	13431587-3501	UT

General Provider Information

NPI Number	:	1457097677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EMMA SULLIVAN

Provider Business Mailing Address
First Line	:	3725 W 4100 S STE 201
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84120-6490
Country	:	US
Telephone Number	:	888-949-4864
Fax Number	:

Provider Business Practice Location Address
First Line	:	3737 W 4100 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84120-5543
Country	:	US
Telephone Number	:	888-949-4864
Fax Number	:

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

Provider Enumeration Date	:	05/10/2022
Last Update Date	:	04/17/2025

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Directions to “ EMMA SULLIVAN ” Practice Location

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