Healthcare Provider Details

I. General information

NPI: 1720934672
Provider Name (Legal Business Name): CELISE KATHLEEN BALLOW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2026
Last Update Date: 03/04/2026
Certification Date: 03/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 W 1000 S APT D107
OREM UT
84058-4124
US

IV. Provider business mailing address

1225 W 1000 S APT D107
OREM UT
84058-4124
US

V. Phone/Fax

Practice location:
  • Phone: 385-436-3176
  • Fax:
Mailing address:
  • Phone: 385-436-3176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: