Healthcare Provider Details

I. General information

NPI: 1194223867
Provider Name (Legal Business Name): COTTONWOOD BEHAVIORAL COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6337 S HIGHLAND DR # 227 SUITE 227
SALT LAKE CITY UT
84121-8558
US

IV. Provider business mailing address

6337 S HIGHLAND DR # 227
SALT LAKE CITY UT
84121-2107
US

V. Phone/Fax

Practice location:
  • Phone: 385-313-9001
  • Fax:
Mailing address:
  • Phone: 385-313-9001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WALTER PERA
Title or Position: PRESIDENT
Credential:
Phone: 801-557-1154