MEDICARE: ISABEL TERESA MOLINA-AVELLA PH.D. SOCIAL WORK

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1669789632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ISABEL TERESA MOLINA-AVELLA PH.D. SOCIAL WORK

Provider Business Mailing Address
First Line	:	1578 W 1700 S
Second Line	:	SUITE 200
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84104-3470
Country	:	US
Telephone Number	:	801-972-2711
Fax Number	:	801-972-2709

Provider Business Practice Location Address
First Line	:	1578 W 1700 S
Second Line	:	SUITE 200
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84104-3470
Country	:	US
Telephone Number	:	801-972-2711
Fax Number	:	801-972-2709

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

Provider Enumeration Date	:	09/10/2010
Last Update Date	:	09/10/2010

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