Healthcare Provider Details

I. General information

NPI: 1245729417
Provider Name (Legal Business Name): MOMENTUM COUNSELING SERVICES, CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 05/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11075 S STATE ST STE 13
SANDY UT
84070-5193
US

IV. Provider business mailing address

1446 E ANVIL DR
DRAPER UT
84020-8832
US

V. Phone/Fax

Practice location:
  • Phone: 801-948-0939
  • Fax:
Mailing address:
  • Phone: 801-898-7502
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number8598755-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number6153954-3902
License Number StateUT

VIII. Authorized Official

Name: TYLER STARK
Title or Position: OWNER
Credential: LCMHC
Phone: 801-518-9362