Healthcare Provider Details

I. General information

NPI: 1013478346
Provider Name (Legal Business Name): KINTSUGI COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 N MAIN ST STE 204
HEBER CITY UT
84032-1671
US

IV. Provider business mailing address

520 N MAIN STREET SUITE C#448
HEBER CITY UT
84032
US

V. Phone/Fax

Practice location:
  • Phone: 435-850-7402
  • Fax: 435-538-7000
Mailing address:
  • Phone: 435-850-7402
  • Fax: 435-538-7000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE EVANS-MCALISTER
Title or Position: MENTAL HEALTH THERAPIST
Credential: LCMHC
Phone: 435-850-7402