Healthcare Provider Details

I. General information

NPI: 1235682345
Provider Name (Legal Business Name): EAGLE RANCH OUTPATIENT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/26/2016
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 W 1470 S SUITE 101
ST GEORGE UT
84770-6709
US

IV. Provider business mailing address

91 W 1470 S SUITE 101
ST GEORGE UT
84770-6709
US

V. Phone/Fax

Practice location:
  • Phone: 435-922-0440
  • Fax:
Mailing address:
  • Phone: 435-922-0440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number53606263904
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number53606266006
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number53606263904
License Number StateUT
# 4
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number5360626 3904
License Number StateUT

VIII. Authorized Official

Name: KELLY BAWDEN
Title or Position: THERAPIST/DIRECTOR
Credential: LMFT
Phone: 435-922-0440