Healthcare Provider Details

I. General information

NPI: 1245705409
Provider Name (Legal Business Name): JOSEPH ELDER CMHC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2018
Last Update Date: 10/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S OREM BLVD
OREM UT
84058-5011
US

IV. Provider business mailing address

901 S OREM BLVD
OREM UT
84058-5011
US

V. Phone/Fax

Practice location:
  • Phone: 801-465-5111
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5804101-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: