MEDICARE: MR. STAN M FILLMORE 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	1041C0700X	Clinical Social Worker	1100853501	UT

General Provider Information

NPI Number	:	1780785329
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STAN M FILLMORE LCSW

Provider Business Mailing Address
First Line	:	PO BOX 1036
Second Line	:	117 W 200 SO
City	:	FARMINGTON
State	:	UT
Zip	:	84025-1036
Country	:	US
Telephone Number	:	801-451-4843
Fax Number	:	801-451-2839

Provider Business Practice Location Address
First Line	:	117 WEST 200 SOUTH
Second Line	:
City	:	FARMINGTON
State	:	UT
Zip	:	84025-1036
Country	:	US
Telephone Number	:	801-451-4843
Fax Number	:	801-451-2839

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	07/08/2007

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