Healthcare Provider Details

I. General information

NPI: 1902236458
Provider Name (Legal Business Name): BONNEVILLE MENTAL HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2013
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

134 W 1180 N STE 4
TOOELE UT
84074-1483
US

IV. Provider business mailing address

134 W 1180 N STE 4
TOOELE UT
84074-1483
US

V. Phone/Fax

Practice location:
  • Phone: 435-228-4181
  • Fax:
Mailing address:
  • Phone: 435-228-4181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number2903
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number2903
License Number StateUT

VIII. Authorized Official

Name: NATE GREEN
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 435-228-4181