MEDICARE: REBECCA CHRISTENSEN FAIRBANKS 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	8890207-3501	UT
2	1041C0700X	Clinical Social Worker	117144	MA

General Provider Information

NPI Number	:	1588089049
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA CHRISTENSEN FAIRBANKS LCSW

Provider Business Mailing Address
First Line	:	1760 W 4805 S
Second Line	:
City	:	TAYLORSVILLE
State	:	UT
Zip	:	84129-1177
Country	:	US
Telephone Number	:	801-955-9110
Fax Number	:	801-955-9411

Provider Business Practice Location Address
First Line	:	2020 S LAKE ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3119
Country	:	US
Telephone Number	:	801-487-7778
Fax Number	:	435-652-6354

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

Provider Enumeration Date	:	02/20/2014
Last Update Date	:	02/20/2014

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Directions to “ REBECCA CHRISTENSEN FAIRBANKS LCSW” Practice Location

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