MEDICARE: ANJELICA MONTESDEOCA

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	101Y00000X	Counselor

General Provider Information

NPI Number	:	1972101384
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANJELICA MONTESDEOCA

Provider Business Mailing Address
First Line	:	1159 RUSHTON ST
Second Line	:
City	:	OGDEN
State	:	UT
Zip	:	84401-0721
Country	:	US
Telephone Number	:	801-603-0874
Fax Number	:

Provider Business Practice Location Address
First Line	:	2655 S LAKE ERIE DR
Second Line	:
City	:	WEST VALLEY CITY
State	:	UT
Zip	:	84120-7350
Country	:	US
Telephone Number	:	385-441-4900
Fax Number	:

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

Provider Enumeration Date	:	10/16/2020
Last Update Date	:	10/16/2020

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