=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326604125
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MESSICK FAMILY COUNSELING LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/16/2019
-----------------------------------------------------
Last Update Date | 06/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 66 W VINE ST # 1
-----------------------------------------------------
City | TOOELE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84074-2185
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-241-4920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 425
-----------------------------------------------------
City | TOOELE
-----------------------------------------------------
State | UT
-----------------------------------------------------
Zip | 84074-0425
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 435-241-4920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. CRYSTAL SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 435-241-4920
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------