MEDICARE: MR. MACHIEL PIETER KLERK LMFT

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	106H00000X	Marriage & Family Therapist	6938635-3902	UT

General Provider Information

NPI Number	:	1942503313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MACHIEL PIETER KLERK LMFT

Provider Business Mailing Address
First Line	:	150 S 600 E STE 7C
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-1989
Country	:	US
Telephone Number	:	801-656-8806
Fax Number	:

Provider Business Practice Location Address
First Line	:	2010 EVERGREEN AVE
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84109-2923
Country	:	US
Telephone Number	:	801-656-8806
Fax Number	:

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

Provider Enumeration Date	:	12/07/2010
Last Update Date	:	12/07/2010

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