MEDICARE: ELISA LEARY

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	104100000X	Social Worker	89125963502	UT

General Provider Information

NPI Number	:	1992112841
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISA LEARY

Provider Business Mailing Address
First Line	:	2020 S LAKE ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3119
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2020 S LAKE ST
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84105-3119
Country	:	US
Telephone Number	:	801-487-7778
Fax Number	:	801-487-2942

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

Provider Enumeration Date	:	07/11/2014
Last Update Date	:	07/11/2014

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Directions to “ ELISA LEARY ” Practice Location

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