MEDICARE: ANGELA MARIE MANDEVILLE CSW

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	6145420-3502	UT

General Provider Information

NPI Number	:	1497706360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA MARIE MANDEVILLE CSW

Provider Business Mailing Address
First Line	:	2766 E 3300 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-2819
Country	:	US
Telephone Number	:	801-467-5437
Fax Number	:	801-466-6643

Provider Business Practice Location Address
First Line	:	2766 E 3300 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-2819
Country	:	US
Telephone Number	:	801-467-5437
Fax Number	:	801-466-6643

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

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	10/29/2009

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