Healthcare Provider Details

I. General information

NPI: 1326304023
Provider Name (Legal Business Name): LIFE ENHANCEMENT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2012
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1835 N 1120 W
PROVO UT
84604-1180
US

IV. Provider business mailing address

1835 N 1120 W
PROVO UT
84604-1180
US

V. Phone/Fax

Practice location:
  • Phone: 801-623-4770
  • Fax: 801-623-4771
Mailing address:
  • Phone: 801-623-4770
  • Fax: 801-623-4771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number5828209-6009
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number5828209-6009
License Number StateUT

VIII. Authorized Official

Name: MRS. SHELLEY MANGUM
Title or Position: ASS. CLINICAL MENTAL HEALTH COUNSEL
Credential: ACMHC
Phone: 801-796-0620