MEDICARE: MR. ISAAC MICHAEL PHILLIPS 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	6613419-3501	UT

General Provider Information

NPI Number	:	1558634725
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ISAAC MICHAEL PHILLIPS LCSW

Provider Business Mailing Address
First Line	:	7745 S 2325 E
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-5668
Country	:	US
Telephone Number	:	801-450-2798
Fax Number	:

Provider Business Practice Location Address
First Line	:	7745 S 2325 E
Second Line	:
City	:	COTTONWOOD HEIGHTS
State	:	UT
Zip	:	84121-5668
Country	:	US
Telephone Number	:	801-450-2798
Fax Number	:

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

Provider Enumeration Date	:	02/17/2012
Last Update Date	:	02/17/2012

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