Healthcare Provider Details

I. General information

NPI: 1053910331
Provider Name (Legal Business Name): MOUNT OLYMPUS COUNSELING CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2020
Last Update Date: 10/19/2020
Certification Date: 10/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4525 S 2300 E STE 102
HOLLADAY UT
84117-4682
US

IV. Provider business mailing address

4525 S 2300 E STE 102
HOLLADAY UT
84117-4682
US

V. Phone/Fax

Practice location:
  • Phone: 801-860-7818
  • Fax:
Mailing address:
  • Phone: 801-860-7818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

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

VIII. Authorized Official

Name: KENNETH DAVID ROACH
Title or Position: EXECUTIVE DIRECTOR
Credential: ED.D, LCMHC
Phone: 801-792-7028