Healthcare Provider Details

I. General information

NPI: 1316339443
Provider Name (Legal Business Name): DOUG AND BETTY FORD COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2015
Last Update Date: 02/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 COUGAR CIR
ELK RIDGE UT
84651-9565
US

IV. Provider business mailing address

PO BOX 222
SALEM UT
84653-0222
US

V. Phone/Fax

Practice location:
  • Phone: 801-921-9495
  • Fax:
Mailing address:
  • Phone: 801-921-9495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3315546004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number49290043501
License Number StateUT

VIII. Authorized Official

Name: CHERYL IPSON
Title or Position: BILLNG MANAGER
Credential:
Phone: 801-921-9495