MEDICARE: MRS. LESLIE M. WHITE MSW, 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	122349-3501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	122349-3501	OTHER	UT	CLINICAL SOCIAL WORKER

General Provider Information

NPI Number	:	1609964659
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LESLIE M. WHITE MSW, LCSW

Provider Business Mailing Address
First Line	:	4190 HIGHLAND DR STE 210
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2674
Country	:	US
Telephone Number	:	801-278-8859
Fax Number	:	801-278-8504

Provider Business Practice Location Address
First Line	:	4190 HIGHLAND DR STE 210
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84124-2674
Country	:	US
Telephone Number	:	801-278-8859
Fax Number	:	801-278-8504

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

Provider Enumeration Date	:	10/11/2006
Last Update Date	:	07/08/2007

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