Healthcare Provider Details

I. General information

NPI: 1679907174
Provider Name (Legal Business Name): EBBIE RUSSETT CMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EBBIE CABRERA

II. Dates (important events)

Enumeration Date: 09/03/2013
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1785 E 1450 S STE 300
CLEARFIELD UT
84015-2299
US

IV. Provider business mailing address

4460 S HIGHLAND DR STE 210
SALT LAKE CITY UT
84124-3550
US

V. Phone/Fax

Practice location:
  • Phone: 888-949-4864
  • Fax:
Mailing address:
  • Phone: 888-949-4864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number9149805-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: