Healthcare Provider Details

I. General information

NPI: 1346161866
Provider Name (Legal Business Name): CREATORS LEGACY OF MIDVALE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6541 S COTTONWOOD ST
SALT LAKE CITY UT
84107-7007
US

IV. Provider business mailing address

636 S 40 E
SALEM UT
84653-9530
US

V. Phone/Fax

Practice location:
  • Phone: 801-946-2323
  • Fax:
Mailing address:
  • Phone: 801-946-2323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code225XP0019X
TaxonomyPhysical Rehabilitation Occupational Therapist
License Number
License Number State

VIII. Authorized Official

Name: MATTHEW JOSEPH VICARIO
Title or Position: CLINICAL DIRECTOR
Credential: CMHC
Phone: 801-946-2323