Healthcare Provider Details

I. General information

NPI: 1639693344
Provider Name (Legal Business Name): DIXIE STATE UNIVERSITY HEALTH & COUNSELING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1037 E 100 S
ST GEORGE UT
84770-3006
US

IV. Provider business mailing address

1037 E 100 S
ST GEORGE UT
84770-3006
US

V. Phone/Fax

Practice location:
  • Phone: 435-652-7756
  • Fax:
Mailing address:
  • Phone: 435-652-7756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7343133-4405
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number50390644405
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License Number50390644405
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1244136008
License Number StateUT
# 6
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number91334252501
License Number StateUT
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1351453501
License Number StateUT
# 8
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number3288013102
License Number StateUT

VIII. Authorized Official

Name: DYLAN MATSUMORI
Title or Position: DIRECTOR
Credential: PH.D.
Phone: 435-652-7756