Healthcare Provider Details

I. General information

NPI: 1447592241
Provider Name (Legal Business Name): HOLBROOK THERAPEUTIC SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12670 N 6500 E
SPRING CITY UT
84662
US

IV. Provider business mailing address

PO BOX 575
SPRING CITY UT
84662-0575
US

V. Phone/Fax

Practice location:
  • Phone: 435-676-3020
  • Fax: 435-462-9839
Mailing address:
  • Phone: 435-676-3020
  • Fax: 435-462-9839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number379899-3501
License Number StateUT

VIII. Authorized Official

Name: GARRY RICHARD HOLBROOK
Title or Position: OWNER/ LCSW
Credential:
Phone: 435-676-3020