MEDICARE: MS. SUSAN A. MITCHELL 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	101Y00000X	Counselor	2662563501	UT
2	101YA0400X	Addiction (Substance Use Disorder) Counselor	2662563501	UT
3	101YM0800X	Mental Health Counselor	2662563501	UT
4	1041C0700X	Clinical Social Worker	2662563501	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	002200233	OTHER	UT	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	107001386101	OTHER	UT	INTERMTN. HEALTH CARE
2	94293834B	OTHER	UT	CHAMPUS
4	262038	OTHER	UT	DESERET MUTUAL
5	942938348MI2	OTHER	UT	EDUCATORS MUTUAL

General Provider Information

NPI Number	:	1710965447
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SUSAN A. MITCHELL LCSW

Provider Business Mailing Address
First Line	:	3051 W MAPLE LOOP DR
Second Line	:	STE 210
City	:	LEHI
State	:	UT
Zip	:	84043-4602
Country	:	US
Telephone Number	:	801-263-7231
Fax Number	:

Provider Business Practice Location Address
First Line	:	5965 S 900 E STE 240
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84121-1720
Country	:	US
Telephone Number	:	801-263-7231
Fax Number	:

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

Provider Enumeration Date	:	01/03/2006
Last Update Date	:	10/28/2016

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