Healthcare Provider Details

I. General information

NPI: 1326410960
Provider Name (Legal Business Name): THE PHOENIX RECOVERY & COUNSELING CENTER - VERNAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 10/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1783 W 1000 S
VERNAL UT
84078-4115
US

IV. Provider business mailing address

1783 W 1000 S
VERNAL UT
84078-4115
US

V. Phone/Fax

Practice location:
  • Phone: 435-709-8399
  • Fax: 801-619-2016
Mailing address:
  • Phone: 435-709-8399
  • Fax: 801-619-2016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number14091
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number14091
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number14091
License Number StateUT
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number14091
License Number StateUT
# 5
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14091
License Number StateUT
# 6
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number14091
License Number StateUT

VIII. Authorized Official

Name: MR. BRADLEY RANDALL CHRISTENSEN
Title or Position: OPERATIONS DIRECTOR
Credential:
Phone: 435-773-5857