Healthcare Provider Details

I. General information

NPI: 1790306652
Provider Name (Legal Business Name): PINNACLE ADDICTION & MENTAL HEALTH THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 12/04/2020
Certification Date: 12/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3507 N UNIVERSITY AVE # 375C
PROVO UT
84604-4478
US

IV. Provider business mailing address

5108 W EAGLE HILL CIR
WEST JORDAN UT
84081-3989
US

V. Phone/Fax

Practice location:
  • Phone: 801-842-8062
  • Fax: 801-305-6006
Mailing address:
  • Phone: 801-842-8062
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STACEY PERKO
Title or Position: OWNER
Credential: LCSW
Phone: 801-842-8062