MEDICARE: MINDY JO VANDERLOO CPCI

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	101YM0800X	Mental Health Counselor	7380258-6009	UT

General Provider Information

NPI Number	:	1699090472
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MINDY JO VANDERLOO CPCI

Provider Business Mailing Address
First Line	:	1390 S 1100 E STE 203
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2463
Country	:	US
Telephone Number	:	801-510-5231
Fax Number	:

Provider Business Practice Location Address
First Line	:	1390 S 1100 E STE 203
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-2463
Country	:	US
Telephone Number	:	801-510-5231
Fax Number	:

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

Provider Enumeration Date	:	04/05/2010
Last Update Date	:	04/05/2010

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