Healthcare Provider Details

I. General information

NPI: 1679885461
Provider Name (Legal Business Name): TERRY NANI NBCC, LPC, MED, MA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2010
Last Update Date: 07/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 EAGLE GLEN CIR
WEST BOUNTIFUL UT
84087-2148
US

IV. Provider business mailing address

1700 EAGLE GLEN CIR
WEST BOUNTIFUL UT
84087-2148
US

V. Phone/Fax

Practice location:
  • Phone: 801-927-7322
  • Fax:
Mailing address:
  • Phone: 801-927-7322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number70321396010
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: