Healthcare Provider Details

I. General information

NPI: 1790899284
Provider Name (Legal Business Name): PRIDE COUNSELING INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/19/2006
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1174 E GRAYSTONE WAY STE 20E
SALT LAKE CITY UT
84106-2678
US

IV. Provider business mailing address

1174 E GRAYSTONE WAY STE 20E
SALT LAKE CITY UT
84106-2678
US

V. Phone/Fax

Practice location:
  • Phone: 801-595-0666
  • Fax: 801-595-0669
Mailing address:
  • Phone: 801-595-0666
  • Fax: 801-595-0669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number140182-3501
License Number StateUT

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier377869655001
Identifier TypeMEDICAID
Identifier StateUT
Identifier Issuer
# 2
Identifier37786965502001
Identifier TypeOTHER
Identifier StateUT
Identifier IssuerBCBS OF UTAH

VIII. Authorized Official

Name: MR. JERRY L BUIE
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LCSW
Phone: 801-595-0666