Healthcare Provider Details

I. General information

NPI: 1265921209
Provider Name (Legal Business Name): BRIAN PACE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 05/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

377 E RIVERSIDE DR STE B
ST GEORGE UT
84790-4749
US

IV. Provider business mailing address

1643 S AGATE CIR
ST GEORGE UT
84790-6109
US

V. Phone/Fax

Practice location:
  • Phone: 435-229-2557
  • Fax:
Mailing address:
  • Phone: 435-229-2557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number92449
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10768634-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: