Healthcare Provider Details

I. General information

NPI: 1568008258
Provider Name (Legal Business Name): CLAIRE DELISE CMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11260 S RIVER HEIGHTS DR
SOUTH JORDAN UT
84095-5119
US

IV. Provider business mailing address

11260 S RIVER HEIGHTS DR
SOUTH JORDAN UT
84095-5119
US

V. Phone/Fax

Practice location:
  • Phone: 385-308-8403
  • Fax:
Mailing address:
  • Phone: 385-308-8403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number11077067-6009
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11077067-6004
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: