MEDICARE: SUEELLEN EBERTZ MSW CSW

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	104100000X	Social Worker	7716151-3502	UT

General Provider Information

NPI Number	:	1780918060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUEELLEN EBERTZ MSW CSW

Provider Business Mailing Address
First Line	:	344 E 100 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1700
Country	:	US
Telephone Number	:	801-322-4257
Fax Number	:	801-322-2831

Provider Business Practice Location Address
First Line	:	344 E 100 S
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84111-1700
Country	:	US
Telephone Number	:	801-322-4257
Fax Number	:	801-322-2831

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

Provider Enumeration Date	:	09/19/2009
Last Update Date	:	02/14/2014

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