Provider Demographics
NPI:1699730812
Name:MECCICO, CAROLIE (LCSW)
Entity type:Individual
Prefix:MS
First Name:CAROLIE
Middle Name:
Last Name:MECCICO
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5315 SOUTH ADAMS AVE.
Mailing Address - Street 2:SUITE B7
Mailing Address - City:WASHINGTON TERRACE
Mailing Address - State:UT
Mailing Address - Zip Code:84405-4509
Mailing Address - Country:US
Mailing Address - Phone:801-528-5054
Mailing Address - Fax:801-479-3997
Practice Address - Street 1:5315 SOUTH ADAMS AVE.
Practice Address - Street 2:SUITE B7
Practice Address - City:WASHINGTON TERRACE
Practice Address - State:UT
Practice Address - Zip Code:84405-4509
Practice Address - Country:US
Practice Address - Phone:801-528-5054
Practice Address - Fax:801-479-3997
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT27660135011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT2766013501OtherSTATE OF UTAH LICENSE #