Healthcare Provider Details

I. General information

NPI: 1992125553
Provider Name (Legal Business Name): THE PHOENIX RECOVERY CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2014
Last Update Date: 04/05/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 W. SOUTH JORDAN PARKWAY STE 400
SOUTH JORDAN UT
84095
US

IV. Provider business mailing address

9980 S 300 W STE 105
SANDY UT
84070-3641
US

V. Phone/Fax

Practice location:
  • Phone: 801-438-3185
  • Fax: 801-438-3184
Mailing address:
  • Phone: 801-438-3185
  • Fax: 801-438-3184

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number5549
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number5549
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number5549
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5549
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number5549
License Number StateUT
# 6
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number5549
License Number StateUT
# 7
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number5549
License Number StateUT

VIII. Authorized Official

Name: KRISTIN TIMMONS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 801-438-3185