Healthcare Provider Details

I. General information

NPI: 1740508993
Provider Name (Legal Business Name): ADOLESCENCE TO ADULTHOOD COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 05/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 N MAIN ST SUITE 1474
NORTH SALT LAKE UT
84054-2162
US

IV. Provider business mailing address

PO BOX 540724
NORTH SALT LAKE UT
84054-0724
US

V. Phone/Fax

Practice location:
  • Phone: 801-891-0400
  • Fax: 801-298-0846
Mailing address:
  • Phone: 801-791-0400
  • Fax: 801-298-0846

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number16382
License Number StateUT

VIII. Authorized Official

Name: MR. KENNETH L HULL
Title or Position: QWNER / CLINICAL DIRECTOR
Credential: LPC
Phone: 801-891-0400