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General NPI Number Information
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NPI Number | 1164398392
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Entity Type | Organization
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Legal Business Name | BROOKSIDE WELLNESS CENTER PLLC
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Dates
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Enumeration Date | 10/14/2025
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Last Update Date | 10/14/2025
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Provider Practice Location Address
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Address Line | 4688 S WALLACE DR UNIT G
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City | SAINT GEORGE
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State | UT
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Zip | 84790-1863
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Country | US
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Telephone | 435-429-1042
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Fax |
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Provider Business Mailing Address
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Address Line | 4688 S WALLACE DR UNIT G
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City | SAINT GEORGE
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State | UT
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Zip | 84790-1863
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Country | US
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Telephone | 435-429-1042
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Fax |
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Authorized Official
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Title or Position | PROGRAM DIRECTOR
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Name | COLBY GANNON BACKMAN
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Credential | CMHC
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Telephone | 435-429-1042
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101200000X
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Taxonomy Name | Drama Therapist
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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