MEDICARE: WASATCH SPRING LLC

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	5417183-3501	UT

General Provider Information

NPI Number	:	1770962292
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WASATCH SPRING LLC

Provider Business Mailing Address
First Line	:	2936 S HIGHLAND DR STE 100
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3584
Country	:	US
Telephone Number	:	801-467-4545
Fax Number	:	866-829-6866

Provider Business Practice Location Address
First Line	:	2936 S HIGHLAND DR STE 100
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84106-3584
Country	:	US
Telephone Number	:	801-467-4545
Fax Number	:	866-829-6866

Authorized Official
Title or Position	:	OWNER
Name	:	SCOTT M HOWES
Credential	:	LCSW
Telephone Number	:	801-467-4545

Provider Enumeration Date	:	05/29/2015
Last Update Date	:	05/29/2015

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