Healthcare Provider Details

I. General information

NPI: 1225326044
Provider Name (Legal Business Name): ST. GEORGE CHILDREN & FAMILY PSYCHIATRIC CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2011
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 N 1680 E STE H1
SAINT GEORGE UT
84790-2584
US

IV. Provider business mailing address

230 N 1680 E STE H1
SAINT GEORGE UT
84790-2584
US

V. Phone/Fax

Practice location:
  • Phone: 435-652-1897
  • Fax: 435-652-5909
Mailing address:
  • Phone: 435-652-1897
  • Fax: 435-652-5909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1494471205
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code364SP0810X
TaxonomyChild & Family Psychiatric/Mental Health Clinical Nurse Specialist
License Number68747874408
License Number StateUT

VIII. Authorized Official

Name: DR. CANTRIL NIELSEN
Title or Position: OWNER
Credential: M.D.
Phone: 435-652-1897