Healthcare Provider Details

I. General information

NPI: 1649914409
Provider Name (Legal Business Name): NICHOLAUS OWEN MOORE CMHC, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2022
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2332 W 12600 S STE 2C
RIVERTON UT
84065-7173
US

IV. Provider business mailing address

2332 W 12600 S STE 2C
RIVERTON UT
84065-7173
US

V. Phone/Fax

Practice location:
  • Phone: 385-402-8651
  • Fax:
Mailing address:
  • Phone: 385-402-8651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14218391-6004
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: