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General NPI Number Information
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NPI Number | 1114277001
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Entity Type | Organization
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Legal Business Name | CIRCLE OF LIFE COUNSELING CENTER, LLC
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Dates
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Enumeration Date | 09/18/2012
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Last Update Date | 02/23/2024
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Provider Practice Location Address
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Address Line | 3375 MAYFLOWER WAY SUITE A
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City | LEHI
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State | UT
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Zip | 84043-3134
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Country | US
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Telephone | 801-331-6775
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Fax | 801-766-2010
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Provider Business Mailing Address
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Address Line | 3375 MAYFLOWER WAY SUITE A
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City | LEHI
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State | UT
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Zip | 84043-3134
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Country | US
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Telephone | 801-331-6775
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Fax | 801-766-2010
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Authorized Official
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Title or Position | CLINICAL DIRECTOR / OWNER
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Name | CARRIE J REALL
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Credential | M.ED., CMHC
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Telephone | 801-331-6775
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6819342-6004
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License Number State | UT
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 5172018-3501
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License Number State | UT
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Taxonomy #3
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 139247-6004
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License Number State | UT
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