Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 62205833501 | UT |
NPI | 1003186438 |
---|---|
Provider Name | Joellyn Orcutt Manville |
First Address | Slc, UT 84111-1247 |
Second Address | Slc, UT 84111-1247 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 02/01/2012 |
Last Update Date | 31/05/2012 |