MEDICARE: LIFE CHANGING THERAPY

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	0683	UT

General Provider Information

NPI Number	:	1477799567
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIFE CHANGING THERAPY

Provider Business Mailing Address
First Line	:	1800 S WEST TEMPLE
Second Line	:	SUITE A332
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-1851
Country	:	US
Telephone Number	:	801-918-9688
Fax Number	:	801-446-7874

Provider Business Practice Location Address
First Line	:	1800 S WEST TEMPLE
Second Line	:	SUITE A332
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84115-1851
Country	:	US
Telephone Number	:	801-918-9688
Fax Number	:	801-446-7874

Authorized Official
Title or Position	:	AGENCY MANAGER
Name	:	MR. RICHARD HOLLIS BASHAW
Credential	:	MSW
Telephone Number	:	801-918-9688

Provider Enumeration Date	:	12/20/2008
Last Update Date	:	12/20/2008

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Directions to “LIFE CHANGING THERAPY ” Practice Location

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