Healthcare Provider Details

I. General information

NPI: 1013218593
Provider Name (Legal Business Name): BRIDGES FORENSIC COUNSELING SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2010
Last Update Date: 12/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

189 S STATE ST SUITE 180
CLEARFIELD UT
84015-1061
US

IV. Provider business mailing address

189 S STATE ST SUITE 180
CLEARFIELD UT
84015-1061
US

V. Phone/Fax

Practice location:
  • Phone: 801-217-3523
  • Fax: 801-217-3723
Mailing address:
  • Phone: 801-217-3523
  • Fax: 801-217-3723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number17035
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. LEE L PERRY
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 801-217-3523