Healthcare Provider Details

I. General information

NPI: 1184009508
Provider Name (Legal Business Name): ADVANCED AWARENESS COUNSELING, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2015
Last Update Date: 07/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4125 N CANYON RD
PROVO UT
84604-5015
US

IV. Provider business mailing address

4141 S HIGHLAND DR SUITE 208
SALT LAKE CITY UT
84124-2642
US

V. Phone/Fax

Practice location:
  • Phone: 408-420-5730
  • Fax:
Mailing address:
  • Phone: 408-420-5730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8173984-6009
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number8173984-6009
License Number StateUT

VIII. Authorized Official

Name: MRS. ELIZABETH V MACIAS
Title or Position: OWNER
Credential: JD
Phone: 408-420-5730