Healthcare Provider Details

I. General information

NPI: 1922550136
Provider Name (Legal Business Name): EXPANSIVE HORIZONS COUNSELING & PSYCHOLOGICAL SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2016
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

228 WEST 200 SOUTH SUITE 2E
KAMAS UT
84036
US

IV. Provider business mailing address

596 ASH COURT
KAMAS UT
84036
US

V. Phone/Fax

Practice location:
  • Phone: 801-360-6955
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8493271-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number8493271-6004
License Number StateUT

VIII. Authorized Official

Name: LIZA SANDERSON
Title or Position: PRESIDENT
Credential: PSYD
Phone: 801-360-6955