Healthcare Provider Details

I. General information

NPI: 1194304931
Provider Name (Legal Business Name): EVOLVING LIGHT COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2021
Last Update Date: 04/07/2021
Certification Date: 04/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 E 100 S STE 202
ST GEORGE UT
84770-3495
US

IV. Provider business mailing address

32 E 100 S STE 202
ST GEORGE UT
84770-3495
US

V. Phone/Fax

Practice location:
  • Phone: 435-668-4956
  • Fax: 702-566-4575
Mailing address:
  • Phone: 435-668-4956
  • Fax: 702-566-4575

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: LAUREY RAY
Title or Position: BILLING/CREDENTIALING
Credential: CMBS
Phone: 702-279-7270