MEDICARE: WICONI COUNSELING CENTER

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1598208928	OTHER		TYPE 1 NPI

General Provider Information

NPI Number	:	1861050783
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WICONI COUNSELING CENTER

Provider Business Mailing Address
First Line	:	1133 N MAIN ST STE 128
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-4830
Country	:	US
Telephone Number	:	801-541-7049
Fax Number	:

Provider Business Practice Location Address
First Line	:	1133 N MAIN ST STE 128
Second Line	:
City	:	LAYTON
State	:	UT
Zip	:	84041-4830
Country	:	US
Telephone Number	:	801-541-7049
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	KIMBERLY MACK
Credential	:
Telephone Number	:	801-503-8093

Provider Enumeration Date	:	06/05/2019
Last Update Date	:	12/18/2019

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