MEDICARE: MIRIAM M DUNFORD 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	133120-3501	UT

General Provider Information

NPI Number	:	1831212711
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRIAM M DUNFORD LCSW

Provider Business Mailing Address
First Line	:	2005 E 2700 S
Second Line	:	SUITE 180
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1700
Country	:	US
Telephone Number	:	801-466-8400
Fax Number	:	801-322-3890

Provider Business Practice Location Address
First Line	:	2005 E 2700 S
Second Line	:	SUITE 180
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-1700
Country	:	US
Telephone Number	:	801-466-8400
Fax Number	:	801-322-3890

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

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

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