MEDICARE: BROOKE ELLISON SKELTON 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	171M00000X	Case Manager/Care Coordinator
2	1041C0700X	Clinical Social Worker	9802741-3502	UT

General Provider Information

NPI Number	:	1548915317
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BROOKE ELLISON SKELTON CSW

Provider Business Mailing Address
First Line	:	327 E 6310 S
Second Line	:
City	:	MURRAY
State	:	UT
Zip	:	84107-7558
Country	:	US
Telephone Number	:	509-879-4743
Fax Number	:

Provider Business Practice Location Address
First Line	:	4905 S 900 E
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84117-5703
Country	:	US
Telephone Number	:	801-869-1095
Fax Number	:	801-869-1096

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

Provider Enumeration Date	:	02/19/2022
Last Update Date	:	05/26/2023

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