Healthcare Provider Details

I. General information

NPI: 1861942864
Provider Name (Legal Business Name): HOLLY PACK SQUIRES LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1258 W SOUTH JORDAN PKWY SUITE 202
SOUTH JORDAN UT
84095-4711
US

IV. Provider business mailing address

1258 W SOUTH JORDAN PKWY SUITE 202
SOUTH JORDAN UT
84095-4711
US

V. Phone/Fax

Practice location:
  • Phone: 801-255-1155
  • Fax:
Mailing address:
  • Phone: 801-255-1155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number9162614-3902
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: