Healthcare Provider Details

I. General information

NPI: 1245010875
Provider Name (Legal Business Name): NELSON LEE CMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 02/06/2026
Certification Date: 02/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 W CANYON CREST RD
ALPINE UT
84004-2061
US

IV. Provider business mailing address

60 W CANYON CREST RD
ALPINE UT
84004-2061
US

V. Phone/Fax

Practice location:
  • Phone: 801-839-5763
  • Fax:
Mailing address:
  • Phone: 801-808-5866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13565339-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: