MEDICARE: MS. CAROLIE MECCICO L.C.S.W.

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	2766013501	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2766013501	OTHER	UT	STATE OF UTAH LICENSE #

General Provider Information

NPI Number	:	1699730812
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROLIE MECCICO L.C.S.W.

Provider Business Mailing Address
First Line	:	5315 SOUTH ADAMS AVE.
Second Line	:	SUITE B7
City	:	WASHINGTON TERRACE
State	:	UT
Zip	:	84405-4509
Country	:	US
Telephone Number	:	801-528-5054
Fax Number	:	801-479-3997

Provider Business Practice Location Address
First Line	:	5315 SOUTH ADAMS AVE.
Second Line	:	SUITE B7
City	:	WASHINGTON TERRACE
State	:	UT
Zip	:	84405-4509
Country	:	US
Telephone Number	:	801-528-5054
Fax Number	:	801-479-3997

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

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	07/08/2007

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