Healthcare Provider Details

I. General information

NPI: 1568510550
Provider Name (Legal Business Name): FAMILY SUPPORT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 W CENTER ST
MIDVALE UT
84047-7148
US

IV. Provider business mailing address

1760 W 4805 S
TAYLORSVILLE UT
84118-1177
US

V. Phone/Fax

Practice location:
  • Phone: 801-955-9411
  • Fax: 801-955-9411
Mailing address:
  • Phone: 801-955-9110
  • Fax: 801-955-9411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number17474
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number12358
License Number StateUT

VIII. Authorized Official

Name: MR. PAUL M. RICKS
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 801-955-9110