Healthcare Provider Details

I. General information

NPI: 1386299287
Provider Name (Legal Business Name): INTERMOUNTAIN COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2019
Last Update Date: 08/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 N MAIN STREET SUITE 200 B
SPRING CITY UT
84662
US

IV. Provider business mailing address

PO BOX 334
MORONI UT
84646-0334
US

V. Phone/Fax

Practice location:
  • Phone: 435-200-3182
  • Fax:
Mailing address:
  • Phone: 435-262-0891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KEVIN BAILEY
Title or Position: PRESIDENT
Credential: LCMHC
Phone: 435-262-0891