MEDICARE: MRS. KASSIDY RAE LOPEZ 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	122470653501	UT

General Provider Information

NPI Number	:	1871291989
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KASSIDY RAE LOPEZ LCSW

Provider Business Mailing Address
First Line	:	1208 E 3300 S
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84106-2522
Country	:	US
Telephone Number	:	801-483-1600
Fax Number	:	801-483-1610

Provider Business Practice Location Address
First Line	:	1208 E 3300 S
Second Line	:
City	:	MILLCREEK
State	:	UT
Zip	:	84106-2522
Country	:	US
Telephone Number	:	801-483-1600
Fax Number	:	801-483-1610

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

Provider Enumeration Date	:	02/17/2023
Last Update Date	:	02/17/2023

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