Healthcare Provider Details

I. General information

NPI: 1154300234
Provider Name (Legal Business Name): AXIS-ONE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 05/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5149 SOUTH 1500 WEST
RIVERDALE UT
84405
US

IV. Provider business mailing address

5149 SOUTH 1500 WEST
RIVERDALE UT
84405
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-0402
  • Fax: 801-475-7464
Mailing address:
  • Phone: 801-475-0402
  • Fax: 801-475-7464

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number47306713501
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1418053501
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number50176303501
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number49189582601
License Number StateUT
# 6
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number2083338900
License Number StateUT
# 7
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3231733501
License Number StateUT

VIII. Authorized Official

Name: MR. EMORY SINGLETARY
Title or Position: EXECUTIVE ADMINISTRATOR
Credential:
Phone: 801-475-0402