Healthcare Provider Details

I. General information

NPI: 1770390668
Provider Name (Legal Business Name): PEPPER ELLIOT LSC, ACMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 12/13/2024
Certification Date: 12/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13774 N JORDANELLE PKWY
KAMAS UT
84036-1391
US

IV. Provider business mailing address

13774 N JORDANELLE PKWY
KAMAS UT
84036-1391
US

V. Phone/Fax

Practice location:
  • Phone: 415-913-8984
  • Fax:
Mailing address:
  • Phone: 415-913-8984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number13780912-6009
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number773132
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: