Healthcare Provider Details

I. General information

NPI: 1225687510
Provider Name (Legal Business Name): MADISON BESSELIEVRE LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2019
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date: 04/17/2026
Reactivation Date: 05/22/2026

III. Provider practice location address

256 N. MAIN ST. SUITE C
ALPINE UT
84004
US

IV. Provider business mailing address

256 N. MAIN ST. SUITE C
ALPINE UT
84004
US

V. Phone/Fax

Practice location:
  • Phone: 801-210-0679
  • Fax: 801-393-4081
Mailing address:
  • Phone: 801-210-0679
  • Fax: 801-393-4081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number14124387-3501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: