Healthcare Provider Details

I. General information

NPI: 1649017104
Provider Name (Legal Business Name): MOONRISE COUNSELING AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/11/2024
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

296 W 100 S
PAYSON UT
84651-2116
US

IV. Provider business mailing address

296 W 100 S
PAYSON UT
84651-2116
US

V. Phone/Fax

Practice location:
  • Phone: 801-473-3645
  • Fax:
Mailing address:
  • Phone: 801-473-3645
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. BROOKLYN ELISE COOK
Title or Position: OWNER/MANAGER
Credential:
Phone: 678-860-0233