MEDICARE: MR. CORY MELVIN SHIPP 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	4933215-3501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	493321535000001	OTHER	UT	BLUE CROSS

General Provider Information

NPI Number	:	1609850221
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CORY MELVIN SHIPP LCSW

Provider Business Mailing Address
First Line	:	1141 E 3900 S
Second Line	:	SUITE A-170
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-1215
Country	:	US
Telephone Number	:	801-284-4990
Fax Number	:	801-284-4991

Provider Business Practice Location Address
First Line	:	1141 EAST 3900 SOUTH
Second Line	:	SUITE A-170
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124
Country	:	US
Telephone Number	:	801-284-4990
Fax Number	:	801-284-4991

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

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	11/03/2009

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