1003186438 NPI number — JOELLYN ORCUTT MANVILLE MSW, LCSW

Table of content: JOELLYN ORCUTT MANVILLE MSW, LCSW (NPI 1003186438)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003186438 NPI number — JOELLYN ORCUTT MANVILLE MSW, LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MANVILLE
Provider First Name:
JOELLYN
Provider Middle Name:
ORCUTT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MSW, LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003186438
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
275 E SOUTH TEMPLE
Provider Second Line Business Mailing Address:
STE 202
Provider Business Mailing Address City Name:
SLC
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84111-1247
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-609-1055
Provider Business Mailing Address Fax Number:
801-953-0271

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
275 E SOUTH TEMPLE
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
SLC
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84111-1247
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-609-1055
Provider Business Practice Location Address Fax Number:
801-953-0271
Provider Enumeration Date:
01/02/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  62205833501 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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