MEDICARE: MS. MARIAN KAYE KNUDSON LCSW

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	137390-3501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	13739035000001	OTHER	UT	BLUE CROSS

General Provider Information

NPI Number	:	1538131461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARIAN KAYE KNUDSON LCSW

Provider Business Mailing Address
First Line	:	5802 S 900 E # 5
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84121-1644
Country	:	US
Telephone Number	:	801-671-3894
Fax Number	:

Provider Business Practice Location Address
First Line	:	5802 S 900 E # 5
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84121-1644
Country	:	US
Telephone Number	:	801-671-3894
Fax Number	:

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

Provider Enumeration Date	:	02/04/2006
Last Update Date	:	09/30/2019

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